Meadows Male, Meadows Female, Balcarres Male and Balcarres Female wards; Royal Edinburgh Hospital, Morningside Terrace, Edinburgh, EH0 5HF
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1 Mental Welfare Commission for Scotland Report on announced/unannounced visit to: Meadows Male, Meadows Female, Balcarres Male and Balcarres Female wards; Royal Edinburgh Hospital, Morningside Terrace, Edinburgh, EH0 5HF Date of visit: 4 February 2016
2 Where we visited The service visited consists of the four wards providing adult acute inpatient psychiatric care for the population of Edinburgh. Each ward is single sex and has 20 beds. Patients from the north of Edinburgh are treated in Balcarres Male and Balcarres Female, and patients from the south of Edinburgh in Meadows Male and Meadows Female. The service is to be relocated to the new Royal Edinburgh Hospital, which is currently being built. It is expected that the move will take place at the end of January We last visited this service on 23 January 2015 and made recommendations about: recording of risk and review of this in patient files need for ongoing maintenance of the wards to maintain acceptable standards prior to re-provisioning need to enforce the no-smoking regulations activity provision in Balcarres male and female patient nursing care plans ensuring appropriate authority is in place for any restrictions On the day of this visit we wanted to follow up on the previous recommendations and also look at psychological therapies provision. Who we met with We met with 23 patients and two relatives. We spoke with: Senior Charge Nurses and staff nurses on the wards; Consultant Clinical Psychologist; the activities coordinator in Balcarres Female; art therapist in Meadows Female. We had a meeting to discuss issues arising from the visit with: the Director of Operations, Royal Edinburgh Hospital and Related Services; Associate Medical Director; Acting Chief Nurse; Clinical Services Development Manager; Clinical Services Manager; Acting Clinical Nurse Manager; Consultant Psychiatrist; and Senior Charge Nurses. In addition, prior to the visit we met with Royal Edinburgh Hospital Patients Council volunteers and two independent patient advocates from AdvoCard (on 1 February 2016). The Patients Council provides collective advocacy. They spoke to us about things they feel are working well in Balcarres and Meadows, and areas where patients have had concerns. It was good to hear that there are processes for patients 1
3 and the Council to discuss issues with the service. It was very helpful for us to have this discussion, and to be able to use information gathered in planning for the visit. Commission visitors Dr Mike Warwick, Medical Officer and visit co-ordinator Mike Diamond, Executive Director (Social Work) Dr Gary Morrison, Executive Director (Medical) Moira Healy, Social Work Officer Margo Fyfe, Nursing Officer Susan Tait, Nursing Officer Graham Morgan, Engagement and Participation Officer (Lived Experience) What people told us and what we found Care, treatment, support and participation Patients we met in all the wards made very positive comments about the care and support they receive from staff. People told us that they have 1:1 sessions with nursing staff, and that staff are available to talk to them at other times if they need support. Patients spoke of having meetings with their Consultants. Those who were well enough to have detailed discussion about their care and treatment were knowledgeable about this. People said they felt involved in their care planning and discharge planning. We met two relatives. One was a relative of a patient who had recently been admitted. The other told us that they were very happy with the care their relative was receiving and that they felt they were kept well informed by staff. We saw evidence in notes we reviewed of good liaison between the multidisciplinary team (MDT) and carers and relatives. This was also evident from some discussions we had about individual patients with staff. Multidisciplinary documentation and review We saw good, comprehensive assessments completed using the Inpatient Care Pathway paperwork. This includes a senior medical review within 24 hours of admission, which is good practice. Entries made by MDT members in the daily notes were comprehensive and we found the notes easy to follow. We saw 1:1 sessions documented by nursing staff. These were not always specifically highlighted. We advise that highlighting these entries would make them easier to identify. Rapid rundown meetings are held in each ward every morning, attended by the Consultants. The team review key clinical issues for patients, such as observation 2
4 status and pass off the ward. An Intensive Home Treatment Team worker also attends, which is good practice. Each Consultant holds a weekly multidisciplinary ward review meeting. This is documented on a coloured sheet that is easily found in the patient s case notes. One of the Consultants is leading development of this Structured Review of Patient Care with key categories under headings forming the acronym SCAMPER. This is being finalised. It will include an attendance list, which is good practice. Risk assessment and management The Inpatient Care Pathway includes risk assessment and management in the initial assessment. Nursing staff complete the Sainsbury s Risk Assessment and Management (Level 1) within 24 hrs of admission. There is a Risk History/Update proforma designed to be updated with subsequent risk events. Senior staff informed us that staff have been somewhat unclear about when to update this form. This needs to be reviewed and clarified. The new Structured Review of Patient Care documentation for the weekly MDT review meeting includes a section for risk assessments. Development of this documentation and its use is a work in progress We hope that these developments will help MDTs documentation of risk assessments and review of risk during admission. We look forward to seeing this in operation on future visits. Nursing care plans We saw nursing care plans written shortly after admission in patients notes. However, we did not find that these care plans had been systematically reviewed and evaluated. We generally did not find nursing care plans for mental health issues written later during the admission. In some of the notes we reviewed there were no nursing care plans to address mental health issues. It was clear from discussions we had with nursing staff that they know patients well, and how best to support them. Person centred care being delivered should be reflected in nursing care plans developed with the patient and regularly reviewed and evaluated. Recommendation 1: Managers should develop collaborative care planning procedures to ensure that all patients have person-centred, Recovery focussed care plans. 3
5 Nursing teams Each ward has a senior Charge Nurse and two Band 6 Charge Nurses. When we last visited we were advised that funding for the second Band 6 positions was temporary. It is good that these posts have been continued. The Senior Charge Nurse and the two band 6 post-holders in Balcarres Female have all changed in the past four months. Staff told us that there have been positive developments in teamworking and sick leave has reduced. Staff nurses told us that staffing levels had impacted on activity and escorting patients out of the ward, but that this was improving. Five staff nurses were due to start on 8 February Psychological therapies A psychologist is providing 0.5 whole time equivalent input across Balcarres Male and Female. This includes 1:1 sessions for individuals and three group sessions per week: Anxiety Management; Emotion Regulation and Compassionate Mind. This is an ongoing pilot that is being evaluated. Nursing staff have received training in Mentalisation Based Therapy (MBT) skills. We discussed these initiatives with the Psychology Lead for Psychosis and Complex Health. Evaluations so far have been positive. Nursing staffing levels have been such that it has not always been possible for nurses to co-facilitate groups. Some staff have found it easier than others to utilise MBT skills in 1:1 sessions with patients. The psychologist said that a nurse-led Self Soothing group was commencing the following weekend. Meadows has no dedicated psychology input, although the Psychology Lead has been providing a limited amount of staff training there. He was concerned that there is no identified funding for dedicated psychology input for the wards after the pilot finishes in September One woman we met in Balcarres Female said she had found attending the Emotion Regulation group helpful. A man we met in Balcarres Male had been having 1:1 sessions with the psychologist but was too unwell to discuss this with us. An art therapist is providing an art therapy group in Meadows Female for 20 weeks and this is being evaluated. A music therapist student is also working with patients in the ward. We had discussion about this psychology and art therapy provision at our end of visit meeting with managers. These initiatives are feeding into the work being done to plan for future delivery of psychological interventions in the new hospital. There will be increased nursing resources, as bed numbers will reduce from 20 to 16 per ward and it is planned to maintain the same staffing levels. 4
6 We are not making a specific recommendation about delivery of psychological therapies at this time, as the need to develop plans for this is being taken forward. There needs to be adequate provision of psychological interventions to meet patients needs across the service. This will need to include training and supervision for nursing staff delivering therapies. We wish to be kept updated on developments. Care for patients with autistic spectrum disorder One patient we met has Asperger s Syndrome. The Charge Nurse said to the Commission visitor that nursing staff have not had any specific training in supporting people with autism spectrum conditions. They said that numbers of people with autism spectrum conditions who are admitted are increasing, and staff would find training helpful. We have provided the Charge Nurse with the link to the NHS Education for Scotland Autism Training Framework ( This training resource would provide useful baseline training, but service managers should review the need for higher level training. Recommendation 2: Service managers should review nursing staff training staff needs in the management of people with autism spectrum disorders and arrange a suitable training programme. Prolonged admissions There are individuals in the wards whose admissions have been prolonged due to awaiting a bed in a rehabilitation ward or community accommodation/support. The week after the visit we asked managers for actual numbers of patients in these categories. Across the four wards, ten patients were awaiting a rehabilitation bed, and 12 were awaiting support/accommodation in the community. We are concerned by the number of patients whose admissions are prolonged. We would like hospital managers to provide us with an update on plans to enable these patients to move on from Meadows and Balcarres. Physical health care Two staff nurses to whom we spoke said that they felt it would be beneficial for staff to have more physical health training, or for there to be Registered General Nurses within the ward teams. The Patients Council also mentioned to us that nursing staff can sometimes seem less confident in managing some physical health issues. We suggest that senior managers consider this feedback. 5
7 Use of mental health and incapacity legislation All detained patients whose prescriptions we reviewed had a consent to treatment (T2) or certificate authorising treatment (T3) form in place to authorise treatment where this was required. This is good practice. We only came across one instance where treatment was prescribed that was not included on the T2 or T3 form in place (a regular anxiolytic was prescribed but the T3 only covered an if required anxiolytic). We drew this to the attention of staff on the day. Rights and restrictions Specified persons One patient we met was detained under the Mental Health Act and required to be prevented from sending s due to risk to himself. There was no legislative authority for this restriction as he had not been made a specified person for safety and security in hospitals under section 286 of the Mental Health Act. This is necessary to provide the appropriate framework for review of the restrictions and the patient with their right to appeal against these. We raised this with staff on the day. The Consultant covering for the patient s Responsible Medical Officer made them a specified person for safety and security in hospitals. Another detained patient was having their access to telephones restricted and supervised. This was properly authorised under specified persons procedures for use of telephones (section 284 of the Mental Health Act). Our specified persons good practice guidance is available on our website. Recommendation 3: Managers should ensure that senior nursing and medical staff are clear about specified persons procedures. Constant observation prescriptions A constant observations prescription sheet is in use which records the nursing support to be provided in a number of circumstances. This is good practice. We advise that sections should be added to this document to record discussion of the observation plan with the patient, their views and whether they are in agreement with this. If the patient is not in agreement with necessary observations, consideration should be given to whether they require to be detained under the Mental Health (Care & Treatment) (Scotland) Act 2003 to authorise this. 6
8 Intramuscular medication prescribed for informal patients Two patients in Balcarres male were prescribed intramuscular (IM) if required psychotropic medication on admission although they were informal. We have concerns about intramuscular if required medication being prescribed for informal patients. This is because it is likely that they would not be consenting to receive the treatment if it was later administered. We consider it best practice for a medical review to be arranged if circumstances arise where intramuscular medication may be required. In adult acute admission wards, administration of if required IM psychotropic medication almost always requires the legislative authority of the Mental Health Act. Therefore we consider that IM if required medication should not be prescribed for informal patients, other than in exceptional cases where staff and a known patient are clear that it is for use in known circumstances where the patient expects they would consent to the treatment. Even then, staff and the patient should be clear that they can withdraw their consent at any time. Recommendation 4: Managers should ensure that intramuscular if required psychotropic medication is not prescribed for informal patients, other than in exceptional individual circumstances. Activity and occupation All the wards have a full time recreation assistant post. Nursing staff also engage in activities and outings with patients. The recreation assistant in Meadows Male had been on sick leave for some time, and the post had been advertised. During our visit nursing staff in Meadows Male were arranging an activities group. The recreation assistants undertake therapeutic outings and activities 1:1 and in groups, including coffee mornings, walking groups and quizzes. Patients who are able to leave the wards can attend the programme of activities at the Hive. The Hive is an activity centre within the Hospital run by SAMH (Scottish Association for Mental Health). The Acting Clinical Nurse Manager informed us that the service is working to increase ward-based activities for people who cannot leave the ward. We are pleased to hear this and would like to be updated on developments. The physical environment We appreciate that the service will be moving to the new Royal Edinburgh Hospital at the end of January The well-recognised issues with the current wards being unsuitable for adult acute inpatients will thus be resolved then. 7
9 When we last visited there were some environmental matters that required to be addressed to make the wards fit for ongoing use. Some of the matters we highlighted in our report have been attended to. However, we are particularly concerned that the female bathroom in Meadows Female remains in a very poor state of repair. This is despite us having made a specific recommendation that this be addressed. We consider that toilets and bathrooms in the wards are in unacceptable condition. Issues between rooms include mould, overly worn fixtures, odour, and flooring separated from the wall with the exposed area dirty (as it cannot be kept clean). Having no choice but to use these facilities, or not bathe in the ward, is demeaning for patients and compromises their dignity. One patient in Meadows Female told us that she finds the toilets unhygienic. A woman in Balcarres Female commented that the bathrooms are awful and not clean enough. We discussed the condition of the toilets and bathrooms at the end of visit meeting. Managers acknowledged that toilets and bathrooms are in poor condition and that it would be desirable to refurbish these in all the wards. It is planned to do this in Meadows Female, and prioritise from there, but insufficient funding was identified as available to undertake this in all four wards. Work has been taken forward to refurbish two single rooms in each of these wards as anti-ligature rooms. Visitors to Balcarres Male noted that the family room was spartan and had three hard chairs in it that were not comfortable to sit on. There are personal safes at patients' bed spaces in the wards. The Patients Council had told us at our meeting with them that these safes tend not to be used, and that people would like to be able to keep possessions safe in their own bed spaces. In one ward we spoke to a staff member who did not know that these safes were there, and said that patients' valuables can be kept in a locked drawer in the duty room. We suggest that Senior Charge Nurses should check that patients know how to use these safes and can do so if they wish to. Recommendation 5: Toilets and bathrooms in all the wards must be refurbished to provide acceptable facilities for patients. The family room in Balcarres Male is spartan and uncomfortable. Managers should address this. Smoking The NHS Lothian smoking policy continues to be unpopular with some patients and challenging for staff to enforce. Several patients mentioned to us that they were unhappy that they cannot smoke in the hospital buildings or grounds. We had 8
10 already heard from the Patients Council that a lot of patients are very unhappy about the situation, including the policy that they cannot smoke if they are being escorted by a nurse outwith the hospital grounds. There are incidents of people smoking in wards. We smelt cigarette smoke in some areas during our visit. Smoking cessation advice is available. Patients can use e-cigarettes in the grounds (but not the buildings) if they are not being escorted by a nurse at the time. Managers told us that they are looking into whether a type of e-cigarette could be prescribed. We appreciate that implementing the NHS Lothian smoking policy is challenging, and would encourage managers to have discussion with other health boards about practice elsewhere. Summary of recommendations 1. Managers should develop collaborative care planning procedures to ensure that all patients have person-centred, Recovery focussed care plans. 2. Service managers should review nursing staff training staff needs in the management of people with autism spectrum disorders and arrange a suitable training programme. 3. Managers should ensure that senior nursing and medical staff are clear about specified persons procedures. 4. Managers should ensure that intramuscular if required psychotropic medication is not prescribed for informal patients, other than in exceptional individual circumstances. 5. Toilets and bathrooms in all the wards must be refurbished to provide acceptable facilities for patients. The family room in Balcarres Male is spartan and uncomfortable. Managers should address this. Good practice As mentioned above, examples of good practice include: A senior medical review is routinely undertaken within 24 hours of admission. Rapid rundown meetings are held in each ward every morning, and attended by the Consultants and an Intensive Home Treatment Team worker. Service response to recommendations The Commission requires a response to these recommendations within three months of the date of this report. A copy of this report will be sent for information to Healthcare Improvement Scotland. Mike Diamond Executive Director (Social Work) 9
11 About the Mental Welfare Commission and our local visits The Commission s key role is to protect and promote the human rights of people with mental illness, learning disabilities, dementia and related conditions. The Commission visits people in a variety of settings. The MWC is part of the UK National Preventive Mechanism, which ensures the UK fulfils its obligations under UN treaties to monitor places where people are detained, prevent ill-treatment, and ensure detention is consistent with international standards When we visit: We find out whether individual care, treatment and support is in line with the law and good practice. We challenge service providers to deliver best practice in mental health, dementia and learning disability care. We follow up on individual cases where we have concerns, and we may investigate further. We provide information, advice and guidance to people we meet with. Where we visit a group of people in a hospital, care home or prison service; we call this a local visit. The visit can be announced or unannounced. In addition to meeting with people who use the service we speak to staff and visitors. Before we visit, we look at information that is publicly available about the service from a variety of sources including Care Inspectorate reports, Healthcare Improvement Scotland inspection reports and Her Majesty s Inspectorate of Prisons inspection reports. We also look at information we have received from other sources, including telephone calls to the Commission, reports of incidents to the Commission, information from callers to our telephone advice line and other sources. Our local visits are not inspections: our report details our findings from the day we visited. Although there are often particular things we want to talk about and look at when we visit, our main source of information on the visit day is from the people who use the service, their carers, staff, our review of the care records and our impressions about the physical environment. When we make recommendations, we expect a response to them within three months (unless we feel the recommendations require an earlier response). 10
12 We may choose to return to the service on an announced or unannounced basis. How often we do this will depend on our findings, the response to any recommendations from the visit and other information we receive after the visit. Further information and frequently asked questions about our local visits can be found on our website. Contact details: The Mental Welfare Commission for Scotland Thistle House 91 Haymarket Terrace Edinburgh EH12 5HE telephone: website: 11
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