Proposal for a pilot of Night Time Confinement for patients at Arnold Lodge Medium Secure Unit, Nottinghamshire Healthcare NHS Trust.

Transcription

1 Proposal for a pilot of Night Time Confinement for patients at Arnold Lodge Medium Secure Unit, Nottinghamshire Healthcare NHS Trust. 1. Introduction This paper has been written to inform the Trust Board of our wish to pilot Night Time Confinement at Arnold Lodge on behalf of the Trust s Medium Secure Services. It is proposed that, subject to satisfactory feedback from a pre-pilot consultation, the pilot would commence on the two male PD wards (Cannock & Ridgeway) on and last for 12 weeks until It is further proposed that in consultation with Dr Louise Braham (Acting Lead Psychologist, Rampton Hospital) we will undertake a pre and post evaluation of the pilot, the findings of which would be considered prior to any further roll out of Night Time Confinement at Arnold Lodge and Wathwood Hospitals. This proposal has the full support of the Arnold Lodge Directorate Management Team (DMT), the Executive Director of Forensic Services, the Deputy Director of Forensic Services and the incoming Executive Director of Forensic Services.. The proposal was fully supported at the Executive Leadership Team meeting on For the purpose of this paper, we are defining Night Time Confinement as the routine predetermined locking up of patients in their bedrooms at night It is further proposed that if the Night Time Confinement pilot is successful, subject to Board approval, a phased rollout across all 7 wards at Arnold Lodge will take place from onwards. Background Arnold Lodge is one of 65 Medium Secure Units in England and Wales. As far as we are aware, we would be the first Medium Secure Unit to confine patients in their bedrooms at night. The proposal to pilot Night Time Confinement at Arnold Lodge follows the successful implementation of Night Time Confinement at Rampton Hospital. Arnold Lodge is a well established and high performing Medium Secure Unit. The Unit has consistently been rated in the top 10 peer reviewed Medium Secure Units in England and Wales, as assessed by the Quality Network Peer Review. Over the past 12 months approximately 64% of admissions have been from prisons and a further 5% from a High Secure Hospital. This is significant in that approximately 70% of our patients will have been used to being confined in their cells/bedrooms at night. 2. Rationale for the proposal The NHS is under considerable financial pressure to generate savings each year. It is anticipated that the current Arnold Lodge budget will decrease over the next 5 years by 2.4 million. The anticipated savings for full Unit-wide implementation at Arnold Lodge would be 486,000. This saving would contribute to the Arnold Lodge CIP plan for 2016/17. The Arnold Lodge DMT has thoroughly investigated a variety of options to achieve the required savings. Actions already taken have included a change in Nursing skill mix, loss of clinical posts, departmental restructures, increase in bed numbers and redundancies. In this climate of CIPs, VThe Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA Chair: Dean Fathers, Chief Executive: Professor Mike Cooke CBE

2 Night Time Confinement has been considered an appropriate and safe way to manage the impact of reduced budgets with the aim being to maintain the quality of patient care and retain a safe and secure environment for patients and staff. The confinement of patients in their ensuite bedrooms at night would enable Arnold Lodge to reduce night staffing levels and protect the active daytime treatment interventions that enable patients to progress to conditions of lower security. The proposal to introduce Night Time Confinement is regarded as an option for achieving the savings required that will have a limited adverse impact on patients and their care pathway. At Arnold Lodge, supportive evidence for this stance was obtained in a recent review of Unit/patient activity in the Unit in December The baseline data demonstrated that in terms of incidents (total no. IR1 s during 2013 = 1917) only 16% (307) of all incidents occurred between the hours of and Patient activity and staff: patient interactions were also reduced significantly. Most patients chose to return to their bedroom before the agreed bed time of midnight. An audit carried out at Arnold Lodge in August 2013 demonstrated that 62 patients (more than 2/3) routinely retired to their bedrooms before midnight to watch tv, listen to music, read or generally relax before going to sleep. 3. Current Situation at Arnold Lodge i) Wards Arnold Lodge currently has 7 wards and a bed capacity of 92, as follows: Rutland Ward (Male Mental Illness) 16 beds Helvellyn Ward (Male Mental Illness) 15 beds Snowdon Ward (Male Mental Illness) 15 beds Cannock Ward (Male PD) 12 beds Ridgeway Ward (Male PD) 12 beds Coniston Ward (Women s Enhanced) 10 beds Tamar Ward (Women s Standard) 12 beds Following the completion of the Phase 3 redevelopment programme in October 2015, Arnold Lodge will have 7 wards and a bed capacity of 100, as follows: Rutland Ward (Male Mental Illness) 14 beds Foxton Ward (Male Mental Illness) 20 beds Thornton Ward (Male Mental Illness) 20 beds Cannock Ward (Male PD) 12 beds Ridgeway Ward (Male PD) 12 beds Coniston Ward (Women s Enhanced) 10 beds Tamar Ward (Women s Standard) 12 beds Patients on Rutland, Ridgeway, Tamar and Coniston Wards have ensuite bedrooms which include a toilet, sink and shower whilst patients on the two redeveloped wards (Foxton and Thornton) and Cannock Ward will have an ensuite toilet and sink. In addition, each Ward bedroom has the facility to access a television (risk assessed). All patient bedrooms at Arnold Lodge have drinking water. At present, all patients are encouraged to vacate the ward day areas by midnight on weekdays (01.00 on Saturday and Sunday nights) and retire to their rooms for the night. Page 2 of 6

3 ii) Staffing 4. Proposal Arnold Lodge currently has a 5 shift pattern which all staff rotate through, as follows: Early Middle Late Twilight Night Arnold Lodge is always responsive to changing clinical need and may increase staffing numbers if patients are in seclusion or placed on increased observations. In addition to the ward staffing numbers, a supernumerary Night Time Duty Coordinator (Band 6 Clinical Team Leader) role is in place (Site Manager) to provide leadership, managerial support, guidance and supervision. This role also exists within day time hours. Arnold Lodge also benefits from a duty/on call system with 24/7 access to a Duty Doctor, Consultant Psychiatrist (and Specialist Registrar on some days), Senior Nurse and Senior Manager. Night staff do have allocated duties to undertake, as required by the ward and include: Communal searches RiO TRIMS entries Ward Round summaries CPA/Tribunal Reports These duties will continue to be undertaken by the night staff once patients have been confined to their bedrooms. A formal Project Management approach would be used to implement the pilot. Every step of the process would be robustly managed including consultation, phased implementation, evaluation etc. No posts will be disestablished during the pilot period. It is proposed that Night Time Confinement should commence at hours and end at hours. This would result in late and night staff undertaking the confinement and early and night staff undertaking the unlock. Please note, in addition to the ward staffing numbers in the tables below, there will be a Band 6 supernumerary Duty Coordinator on duty 24/7 Pre pilot staffing levels will be as per the table below: Ward Days AM Middle Days PM Twilight Nights Coniston Tamar Rutland Thornton Page 3 of 6

4 Foxton Cannock Ridgeway TOTAL Pilot staffing levels from (PD Wards Cannock & Ridgeway) would be as per the table below: Ward Days AM Middle Days PM Twilight Nights Cannock Ridgeway TOTAL Following a phased Unit wide implementation across the remaining 5 wards (if agreed) staffing levels after (phased rollout throughout the year) would be as per below: Ward Days AM Middle Days PM Twilight Nights Coniston Tamar Rutland Thornton Foxton Cannock Ridgeway TOTAL The minimum staffing requirement on any ward would be one qualified and one unqualified Nurse. The proposed night staffing numbers are sufficient to allow staff to take their unpaid break of 30 minutes. Subject to a successful pilot, the associated change to the shift patterns would be the loss of the twilight shift. Unit wide, 7 staff would be lost from the twilight shift, staffing numbers on the late shift would increase by 7 staff and staffing numbers on night shifts would reduce by 6 staff. This would result in the loss of 14.7 wte Band 2 staff Unit wide, it is envisaged that the reduction in posts would be achieved through natural turnover. The role of Night Time Duty Co-ordinator and on call systems would not change. 5. Environmental Preparations: By , Foxton and Thornton wards will have been refurbished and will be ready for Night Time Confinement. Funding would need to be identified and the following works would need to be undertaken to make the other 5 wards Night Time Confinement ready. The pilot would not take place until this work had been completed: Page 4 of 6

5 Cannock - Nurse call system. - Upgrading of the bedroom doors including the installation of a pill hatch and strengthening of door frames. - Replacement ceilings. - Isolations of services (water and power) by individual bedrooms, from the outside of the room. - Wall mounted casings for TVs in identified bedrooms (for patients without access to their own TVs). Ridgeway, Tamar & Coniston - Nurse call system. - Installation of a pill hatch in the bedroom door. - Wall mounted casings for TVs in identified bedrooms (for patients without access to their own TVs). Rutland - Installation of a pill hatch in the bedroom door. - Wall mounted casings for TVs in identified bedrooms (for patients without access to their own TVs). It must be noted that the construction of walls on Thornton, Foxton and Cannock are not of the standard of construction in the newer wards (ie Rutland, Ridgeway, Coniston and Tamar) as they are single brick as opposed to blockwork. Therefore, in a concerted and prolonged attack on a strengthened door and frame the surrounding wall may fail showing signs of obvious cracking and structural damage. However, the proposed door set has been subjected to both a standard medium secure destruction test and enhanced testing, the latter having been undertaken by the MVA Team from Rampton Hospital. Senior Security staff from Rampton were also in attendance to observe the process in addition to Capital Planning Unit representatives and staff from Arnold Lodge. The results from the enhanced test were that the MVA team were unable to breach the door with body impact testing which was carried out over a 20 minute period. The test was therefore considered to be a success 6. Additional Considerations Local procedures will need to be in place to facilitate the removal of patients from their bedroom should they be in crisis and require additional support. Clinical Teams will have the option to care plan for a patient to opt out of Night Time Confinement where clinical need dictates. The Night Time Duty Co-ordinator will be on duty every night with a remit of providing support, guidance and co-ordination of resources to night staff across the Unit. Arnold Lodge will not be complacent over the impact that Night Time Confinement may have on patient wellbeing and each patient will be reviewed on a 3 monthly basis by their Responsible Clinician led Clinical Team. 7. Anticipated Outcome If the pilot is successful and Night Time Confinement is rolled out across the Unit, the movement of staff from the twilight shift to the late shift will release resources to the period when patients are actively engaged in therapeutic interventions. This may provide the following outcomes: Enhance patient access to activities and functions during the therapeutic day. Enhance the ability to consistently meet activity targets. Page 5 of 6

6 8. Next Steps Support the attendance of patients to physical, social, educational and treatment activities. Increase the range of activities on offer to patients during the late shift period, particularly between 1.10 pm to 4.20 pm when the staff to patient ratio will be increased. Patients report increased feelings of safety (feedback from Rampton Hospital). Anecdotal evidence that patients are more rested and better able to focus on daytime activity Increase in activities on offer and patient uptake (feedback from Ashworth Hospital) Enable more Nursing input into group / individual therapies and the assessment process. Increased supervision opportunities for staff. Continue to meet supervision / training / development requirements without depleting ward resources. Meet CIP targets. Subject to Board approval: - Identify key stakeholders and agree pre pilot consultation process and timescales (eg patients, staff, carers, DoH, NHS England, CQC etc). - Develop Project Plan. - Agree ongoing monitoring and reporting mechanisms for the implementation of the project to key stakeholders. Dr Steve Geelan Hazel Hayward Dave Owen Clinical Director & General Manager & Junior Matron Page 6 of 6