Standards for Medium Secure Services Quality Network for Forensic Mental Health Services

Transcription

1 Standards for Medium Secure Services Quality Network for Forensic Mental Health Services CCQI178 June 2014

2 The Quality Network ran a competition to find a piece of patient artwork to use on the front cover of the Standards for Medium Secure Services. The winning design on the front cover is named It is Tomorrow s Dream that will Survive and came from a patient at The Spinney MSU, Partnerships in Care. 2

3 Contents Foreword 4 Method 5 Standards for Medium Secure Services 7 Patient Safety 8 Physical Security 8 Procedural Security 12 Relational Security 15 Safeguarding Children & Vulnerable Adults 16 Patient Experience 17 Patient Focus 17 Family & Friends 19 Environment & Facilities 20 Clinical Effectiveness 22 Patient Pathways & Outcomes 22 Physical Healthcare 25 Workforce 26 Governance 29 Governance 29 Appendix 1: Literature Review 31 Appendix 2: Acknowledgements 40 Appendix 3: Standards Development Working Group 41 Appendix 4: Delegates Stakeholder Consultation Event 42 Appendix 5: Patient Reviewers and Family & Friends Representatives 46 Appendix 6: Project Team 47 Appendix 7: Glossary 48 3

4 Foreword In a time of strategic change it is more important than ever that we can demonstrate the quality of our care in forensic mental health services. The Quality Network provides the ideal framework to support clinicians, senior managers, frontline staff and patients to work together to improve quality year on year. In this context it is a pleasure to welcome these updated Standards for Medium Secure Services. Providing the basis for the Quality Network s self- and peer-reviews they are an accessible way for services to engage in comprehensive on-going service development and improvement for the benefit of patients. The Best Practice Guidance: Specification for adult medium secure units was published by the Department of Health in July From this time it has formed the basis of the Implementation Criteria used by the Quality Network for Forensic Mental Health Services in annual self- and peerreviews of medium secure services nationally. In 2010 the DH commissioned the Quality Network to review the 2007 Best Practice Guidance and this had been intended to constitute the first stage of a more expansive programme led by the DH. This wider process is outstanding and well overdue. In particular, national findings from the Quality Network show a steady increase of the number of standards met by services over the past 4 years and that in most standards were met by most services. This indicated the need to review the standards and to drive up quality nationally. Over the next year NHS England expect to be working closely with the Quality Network for Forensic Mental Health Services to use these Standards and the Quality Network s on-going annual review Cycle to provide an on-going national structure for quality assurance and improvement in Medium Secure Units. Patrick Neville Portfolio Director (Mental Health) NHS England Medical Directorate Specialised Services 4

5 Method These standards have been edited by Sarah Tucker, Programme Manager, Quality Network for Forensic Mental Health Services () and developed in the following way: 1. Literature Review A literature review and review of key documents was carried out by Dr Catherine Durkin, Specialist Registrar in Forensic Psychiatry, South West London & St Georges Mental Health Trust. It appears in this document with a list of documents referred to in Appendix Standards Development Working Group Dr Paul Gilluley, Chair of Advisory Group, chaired a Standards Development Working Group (see Appendix 3). The tasks of this group were to: i. Review existing standards used by the (Implementation Criteria for Recommended Specification: Adult Medium Secure Units) ii. iii. Draw out key themes from the literature review Review of leaflets developed from workshops designed to troubleshoot problems and share good practice and add standards on the basis of these iv. Remove the standards no longer required v. Add further standards vi. Edit existing standards to make them more challenging to achieve vii. Develop a 1 st consultation draft of new standards under the headings; Patient Safety, Patient Experience, Clinical Effectiveness and Governance 3. Standards Consultation Event The hosted a standards consultation event on 18 March 2014 for key stakeholders to comment on the 1 st draft of the revised standards. The event was attended by about 100 stakeholders including commissioners, senior managers, MDT staff, frontline staff, patients, family and friends (see Appendix 4). Following a brief introductory presentation on the process of development of the 1 st draft of the standards, delegates worked in small groups making verbal and written comments on the standards before feeding back at the end of the day. The delegates were asked to remove the standards no longer required, add further standards and edit existing standards to make them more challenging to achieve. 5

6 4. Consultation with Patient Reviewers and Family & Friends Representatives. Patient Reviewers and Family & Friends Representative groups were asked to provide feedback on the 1 st draft of the revised standards both in focus groups and electronically (see Appendix 5). These two groups were asked to remove the standards no longer required, add further standards and edit existing standards to make them more challenging to achieve. 5. Electronic Consultation On the basis of the feedback provided at the consultation event and by the Patient Reviewers and Family & Friends Representative groups, a 2 nd draft of the revised standards was edited. In April 2014 this was sent electronically to all the contacts including membership, MSU and LSU discussion groups, delegates of recent training events and workshops, NHS England and Commissioners. Again people were asked to remove the standards no longer required, add further standards and edit existing standards to make them more challenging to achieve. 6. Further Consultation The 2 nd draft of the standards was further consulted on in a workshop on 1 May 2014 at the Annual Forum of the Medium Secure Services Conference. In addition Elizabeth Allen (Independent Advisor) and Bill Abbott (OBE - Independent Secure Services Policy Advisor) provided independent consultancy on this draft which was then edited to form the final edition of the standards for publication (see Appendix 2). 6

7 Standards for Medium Secure Services Quality Network for Forensic Mental Health Services 7

8 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Patient Safety Physical Security There is a Physical Security Document (PSD) that describes the physical security in place and clearly defines the secure perimeter line. The medium secure unit has a secure perimeter of 5.2 metres. Where building roofs form part of the perimeter or surround patient areas they are protected against climbing to prevent access to the roof. Where the perimeter fence meets buildings or other fences there are no gaps between the joins. There is a daily recorded inspection of the perimeter. There is evidence of immediate remediation of problems reported from daily perimeter checks which is reported to governance meetings on a monthly basis. There is no shrubbery or trellis close to or on the perimeter fence or buildings that form the perimeter. The secure area of the perimeter is well lit. There is a recorded maintenance programme specifically for the perimeter. The perimeter fencing posts are on the non-patient side of the fence. There are essential gate entry points only in the secure perimeter. A1* c A2* A17* A10* A4* A5 A6* c d A7* d A8* A11* 8

9 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) 12 Pedestrian gate entry points in the external secure perimeter operate with either an air-lock system or a double locked gate on a separate locking suite with keys issued, accounted for and controlled by reception. A12* 13 Gate locks are integral to the gates. A14* Gate locks are not accessible from the external side of the perimeter. Gate lock design and secure ground bolt fittings cannot be used to aid climbing. Gates are fitted to prevent egress under the gate. Gates are fitted with double skinning to assist in the prevention of climbing. Gate housings do not provide a climbing aid with adjoining buildings. There is a secure door locking system in place, either manual, electronic, magnetic or a combination of such. Furniture is fixed in all courtyards. In courtyards access doors, doors to stores or facilities, lighting postings, fixings, CCTV fixings, sports fixings etc. do not provide a climbing aid. Windows that form part of the external secure perimeter do not open more than 125mm and can be locked open as well as locked shut. Windows and frames are set within the building masonry. Ceiling designs do not allow patients access to the ceiling/roof void. The reception/ control room is within the secure area or forms part of the secure external perimeter. A14.1* A15.1* A15.2* A15.3* A16* A25* A19* A19.2* A22* A23* A24* A9* 9

10 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) The reception/control room is either fully operational 24 hours per day 7 days week or has in place a system of working to ensure that it can be made fully operational in the case of an emergency. There is a key management system in place in the reception/control room which accounts for all secure keys/passes. Spare replacement keys are under the control of a senior manager and held securely away from reception. Secure pass keys are on a sealed ring and secured to staff at all times during use only secure pass keys are on this ring. Secure pass keys are not ever taken out of the secure external perimeter. There is a process of validation of key holders with appropriate identification and checks before authorised key holders are issued with keys. There is a system to periodically check the authorised key holder list and keep it up to date with leavers and people whose security update training has lapsed. No person is issued keys until they have undertaken a security induction. Locks within the secure area, that provide access to courtyards or open areas within the perimeter, are on a separate suite from internal pass doors. Keys to medication storage are always attached to a qualified member of staff issued and accounted for within the ward. A27* A28* A28.2 A28.4 A30 A28.5 A29* A29.1 A33 A35* 10

11 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) There should be an alarm system in place that allows staff and visitors to raise the alarm in an emergency. Where CCTV is in use, reception/control room should monitor coverage of the perimeter, reception frontage and access from the secure area to reception either physically or by a smart alarm system. A36* A37* f a 11

12 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Procedural Security There is a Procedural Security Index Document (PSID) that lists the procedural policies and is kept up to date. There is a system in place that helps staff understand which policies and procedures are most critical to the safe and effective execution of their role. There are systems in place to assess staff knowledge of policies critical to their role. There are policies in place on the following: A f h b a a a b a a a 41 Searching A c 42 The prevention and de-escalation of violence and aggression. A52 43 The use of seclusion. A a 44 The use and administration of forced medication including rapid tranquilisation. A54 45 Additional patient observation. A55 46 Anti-bullying A The prevention of suicide and management of self-harm. The transportation and movement of patients outside the secure perimeter. Planned and unplanned leave of absence. Substance misuse and the control of illegal substances. A57 A58 A61 A62 A a m q b b d a b d e g l 12

13 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) The control of prescribed medication and drugs. The prosecution of offences within the unit. A64 A65 53 Patient possessions. A66 54 The management of smoking. A The management of patient s allowances and money. The risk assessment and censorship of material including pornography. The use and control of mail and telephones. A68 A69 A70 58 The control of tools. A71 59 Prohibited items. A72 60 The use of computing equipment and access to the internet. A73 F15 61 Visiting A The management and reporting of serious untoward incidents. Monitoring access to and egress from the ward. A76* NEW a d a b d e f g l m c m m k l h b a b d e f g c m c e m d e a f g c 64 Patient count checks. A77* 13

14 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) 65 Patient capacity and consent. A81 66 Equality and diversity. A The response to alarms (Attacks on perimeter Inc.: CCTV, Radio, Alarms. Attacks on people, cover hospital response to patients testing alarms to discourage). The control, issue, checking and maintenance of keys and locks. There is a process in place to enable patients and their representatives to view policies critical to their care. A b c h e i a c 14

15 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Relational Security There is a training programme for all staff that specifically addresses issues of relational security. Key elements of relational security are addressed in core update training. All staff should be issued with guidance on the key elements of relational security. There are clear and effective systems for communication and handover within and between staff teams. There are regular multidisciplinary forums where people have the opportunity to discuss the concerns they have and other issues of relational security. The service has access to an accredited psychotherapist with a psychodynamic or psychoanalytic training and forensic experience once a month as a minimum who is available to support: assessment, supervision, consultation, training and reflective practice. There is a process in place to monitor how the service is performing against items relevant to relational security and an action plan is in place to address any issues raised. A92 A92 A102 B30 Psychoth erapy standard s b a c b g b d c 15

16 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Safeguarding Children & Vulnerable Adults On admission, a record is made for each patient of any children known to be in their social network, their relationship to those children and any known risks whether or not reflected in convictions. Staff training plans include safeguarding children and vulnerable adults. There is a designated Lead for Safeguarding Children. There is a system in place to identify themes and trends in Safeguarding of Vulnerable Adults referrals and shared learning e.g. evidence of communication about culture on wards to senior managers. Staff can demonstrate appropriate identification of patients eligible for notification, and referral for Multi-Agency Public Protection Arrangements (MAPPA) oversight. MAPPA eligible patients should be identified within 3 days of admission/sentence; notification when S. 17 leave is granted and when discharge is considered. There is a Safeguarding Adult Lead within the service to give advice and ensure that all safeguarding issues are raised and resolved, in line with local policy. NEW A130* A131* e a b a e i b b a b 16

17 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Patient Experience Patient Focus Feedback from patients and families is used to improve service quality. Patients are consulted about the unit environment. Where safe to do so, patients are able to personalise their bedroom spaces. Patients that need it are supported with washing, bathing, eating etc. Staff behave in a respectful way toward patients and their families. Patient's rights and what they can expect are explained. This forms part of the patient induction pack, is documented and regularly reviewed. There is a civil advocate available to all patients for face-to-face contact at key points in the patients care pathway. Patient issues raised with independent advocacy and reported to the service are formally discussed at senior management level. D22 D20 D j a c a b c f j 4.9.4a 4.9.4c 4.9.4e d d a l D1* j D13 D17 D10* a b c i e a e g g a c h a h a 17

18 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) There is a multi-faith room appropriately furnished and available for use by all patients. There is evidence that the service is culturally sensitive. Patients are provided with meals made of fresh ingredients which offer choice, address nutritional/balanced diet and specific dietary requirements and which are also sufficient in quantity, are varied and appealing and reflect individual s cultural and religious needs D7* i C10 D a b c d f h 18

19 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Family & Friends 94 There is an engagement strategy for the service that addresses how families and friends are involved and recognised in the provision of care. D8* j d 95 With patient consent, staff actively work with family and friends providing practical, education and emotional support in the form of a programme of regular meetings. D12 96 The MDT takes account of the needs of family and whether by providing support for the family they can better achieve recovery outcomes and prevent relapse for the patient. Carer 2 97 Where safe to do so, staff endeavour to help patients see friends and family in the environment the patient and family considers most dignifying, i.e. ward, garden a 98 The service provides links to local Carer Advocacy services. Carer 1 19

20 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Environment & Facilities The main entrance where visitors are expected to wait is welcoming, has comfortable seating and provides a positive first impression. The unit is clean and maintained to a high standard. There is an appropriately decorated and equipped child and family visiting room. The unit has dedicated spaces for patients within the secure perimeter for: Education OT, psychology and therapy Tribunal suite Library/reading Multi-faith room Physical exercise Primary health provision Self-catering/cooking Dining Shop /café The unit has dedicated spaces for staff for: Confidential working Staff learning and development Dining and rest Changing and secure storage There is evidence that the ward is organised in such a way that enables staff to both observe and engage with patients. There is a central and clearly visible point in the ward, with good lines of sight where patients can easily communicate and engage with staff and from which ward activity can be coordinated. F d h A a A46 A g a i m f k p p 20

21 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) There is an imaginative range of age, gender and risk appropriate ward based activities available for patients. High-risk areas (those not continually observable by staff) minimise the opportunity for selfharm. There is an easily observable and secure treatment and dispensary room. There is a fully wheelchair accessible communal bathroom. There are facilities for patients to make their own hot and cold drinks and snacks. There is a facility for patients to make private phone calls. There is a facility for patients to video-conference. Patients have their own en-suite bedroom with natural light and control over their own ventilation. Bedrooms have patient operated privacy locks that staff can override from the outside. Each bedroom has a staff call facility. There is a de-escalation room or area providing a quiet, low stimulus space for patients experiencing high levels of arousal. Where seclusion facilities exist they fulfil guidance for seclusion in the Medium Secure Environmental Design Guide (April 2011) There is ward-level access from a communal area to a dedicated secure garden that allows patients to access fresh air regularly. F13 D15 /F3 A42 Seclusion standard s G a p f c h 4.9.4f f l f a a h c m m c 21

22 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Clinical Effectiveness Patient Pathways & Outcomes There is a clinical model that describes the purpose of the service and details clinical approach in relation to key therapeutic outcome areas. There are multidisciplinary preadmission assessments for all patients, involving family/friends where possible, that ensure admissions to the service are appropriate. Where possible, patients have information about the service and what to expect before admission. Patients undertake an appropriate evidence-based risk assessment. The purpose and outcome of risk assessments is explained to patients. Patients have a pathway of care planned that is realistic and takes account of their aspirations. The plan identifies services the patient is likely to need through to the community or to the last realistic point of care. Patients have clear personalised outcomes identified in key (if relevant) recovery areas such as: Mental health recovery Insight Problem behaviours and risk Drugs and alcohol Independent living skills Physical health /A85 D17 Goal 2 CQUIN/ A96 A99 Outcome schedule l a a e g 4.9.4e 4.9.4g b c b c a b a e d a b a e d 22

23 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Patients understand which outcomes are pathway critical i.e. what they must achieve to progress to the next level of care. Patients have a personalised plan of therapeutic and skilldeveloping activity that is directly correlated to their outcomes plan. Patients can see the connection between activities they are undertaking and the achievement of their recovery goals. There is evidence of a proactive approach to promoting vocational skills/opportunities for patients. Therapeutic and skill development interventions are evidence based and prescribed by need. The MDT regularly discusses with the patient realistic expectations in relation to length of stay and identifies obstacles or delays (patient, service or commissioning) to progression. Patients can meet their MDT care team at least monthly to review their care, outcomes plans and progress. Patients have a CPA meeting within the first two months and as a minimum every three months thereafter to review ongoing outcomes work and progress. Patients can prepare for any formal review of care (ward round/cpa etc.) and are supported to do so if required Patients are encouraged and supported to be fully involved in their CPA meeting. A94.6 A a A m /A89 A89 A100 / B2 B13 CPA Standard s a g a e 23

24 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) The service works proactively with the next point of care (including other in-patient services, forensic outreach teams, community mental health teams or prison) to develop robust discharge/transfer arrangements and minimise delay. Patient discharge plans feature triggers and arrangements for recall to the service/level of care if the patient relapses. B11* A a c 24

25 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Physical Healthcare Patients have access to health promotion services and information about the range of treatments available. Patients have their physical healthcare needs assessed on admission and reviewed every six months or more frequently if required. Screening programmes are available in line with those available to the general population with the aim of ensuring early diagnosis and prevention of further ill health. Patient plans specify outcomes and interventions in the following areas: Health awareness Weight management Smoking Diet and nutrition Exercise Any patient specific items Patients have access to primary healthcare professionals within the same timeframes expected for the general population. There is a policy and supporting procedure in place for managing emergency response to physical ill health both within the service and transfer to acute care. G15 G6 G11 G12 G3 G3.1 G5 G1 E11 E11 E e 4.9.4a a c c f c a a b e a p j 25

26 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Workforce There is evidence that teams consistently work together in a multidisciplinary way furthering the interests of the patient and the service. There is a workforce plan in place that reflects the needs and risks of the patients in the service. The plan should address: MDT working Safe staffing levels for services The use and security restrictions of agency/temporary workers Recruitment and retention strategy Training Supervision & reflective practice Personal development All staff who hold keys and/or have contact with patients have had enhanced DBS checks. The unit is staffed by directly contracted staff and agency staff are used only in exceptional circumstances. There is a senior member of staff who holds responsibility for physical, procedural and relational security across the service, and who has access to the chief accountable officer responsible for the service. A104 B17 B18 A88 A112 A a c a a c c a d 26

27 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) All staff undertake the mandatory training required for their role. All staff who are expected to have contact with patients receive the following service specific training before doing so: A patient s perspective Recovery and outcomes approach Security training (physical, procedural, relational) Drug and illicit substance awareness Equality and diversity First aid. All staff complete an annual update training which includes: A patient s perspective Recovery and outcomes approach Security training (physical, procedural, relational) Drug and illicit substance awareness Equality and diversity First aid. There is a programme of continued professional development (CPD) and personal development plans (PDPs) for all staff that are annually reviewed and referred to on a monthly basis in supervision with evidence that professional groups can access CPD in line with professional body requirements. The service communicates clearly to front-line staff (including unqualified staff) the purpose and value of supervision. C7 C5* A91 A d a a d k g b e g h a b a a d a b a c c 27

28 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) 154 Staff receive regular management supervision totalling at least one hour per month from a person with appropriate experience. A90* B d a b a c Staff receive regular clinical supervision totalling at least one hour per month There is a system to record and rate staff supervision. Attendance at regular supervision constitutes a mandatory part of all job roles. Staff with supervisory roles receive training in supervision skills. There is a programme of employee assistance and/or counselling available to all staff. There is evidence that staff are aware of the need and feel confident to raise honestly held concerns about issues of patient care, a breach of safety or trust etc. Reasons for staff leaving are recorded through an exit process and reported to the board. A90 B28 / C11 C11.1 B c c c c a 28

29 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) Governance Governance There are clear lines of accountability for the service from ward to board. There is routine sharing of information from ward to board and board to ward that clearly speaks to the quality and effectiveness of care. There is a service-wide risk management and clinical governance strategy that is shared with commissioners. The service has in place a clear strategy of how it engages with all external stakeholders for the benefit of patients and for the service. The service has a clear set of controls in place for managing information governance within the legal requirement. There is a clear system in place to identify, record, report and follow up Serious Incidents Requiring Investigation. There is a system in place to ensure organisation wide learning from incidents and nearmisses. There is evidence of a culture of quality improvement throughout the service. There is evidence that the service is connected to other services, shares good practice and endeavours to stay up-to-date to provide high-class services. C29 A125* A126* A127* A127.1 C21 C22 C c c a e 4.9.4b d b e f g a b c 4.9.4b c b 29

30 No. Standard MSU criteria No. Essential Standards of Quality & Safety(CQC March 2010) There is a programme of exercise (desk-top and live) that enables the development and testing of service contingency plans. Service contingency plans are agreed with the agencies necessary to execute the plan. There is a widely accessible complaints procedure that clearly sets out the ways in which a complaint can be made, the process for investigation and how communication is managed throughout. Patients, patient representatives and families are involved in the development and review of complaints systems. Staff are made aware of any complaint that directly concerns them and of the outcome of that complaint. Patients, their families and friends (where the patient consents) are involved in the complaints process from start to finish and regularly updated on the progress of investigation. Complaints are reviewed quarterly to identify themes, trends and learning. A79 A79.1 A78 C1 C1.1* D14 C d 4.9.4b e h b h a a a e a c a e h a a a e 30

31 Appendix 1: Literature Review Dr Catherine Durkin - Specialist Registrar in Forensic Psychiatry, South West London & St Georges Mental Health Trust A literature review of nationally agreed standards, guidance frameworks, legislation and mental health literature was undertaken in order to update the Medium Secure Unit (MSU) standards produced in Three broad categories of documents were identified as relevant when considering revisions to standards: changes affecting the operation of the NHS as a whole, changes specific to mental health services and changes relating to secure services and in particular, MSUs. 1. Standards Relating to General Healthcare Provision Over the past seven years since the previous standards for MSUs were developed there has been a significant shift in the structure and culture of the NHS. Much of this has been borne out of the changing economic landscape, however it has also been attributable to failings within the system and a need for a new vision for the NHS based on, above all else, patient safety. The recommendations from the key documents leading this review were incorporated into the development of the current MSU standards. In June 2008 Lord Darzi s final review High Quality Care for All was published 1. This outlined a 10 year vision to develop a world class NHS based on the central tenants of equity, personalisation and safety. It was released in tandem with two other central documents: A Consultation on the NHS Constitution 2 (which has since been revised) and A High Quality Workforce: NHS Next Stage Review 3 which outlined the core principles of the NHS to its staff and the public. The vision was for an NHS that gives patients and the public more information and choice, works in partnership and has quality of care at its heart 1. It defined quality as that which is clinically effective, personal and safe 1. It set about trying to tackle the inequalities in provision of local healthcare and trying to make services more personalised, increasing patient choice and involvement in the process. Quality would be linked to payments for hospitals and commissioners would have greater accountability for patient pathways. An additional recommendation was the empowerment of frontline staff via education and training as a means to improve quality. The 2010 White Paper Equity and Excellence: Liberating the NHS 4 set out the Governments long term vision for the future of the NHS. A comprehensive service, available to all, free at the point of use, based on need and not ability to pay. Patients should be at the heart of everything that it does with a focus on improving outcomes, innovation and quality. The subsequent NHS Outcomes Frameworks 5 have developed these themes in order to provide a national indicator of how well the NHS is performing. 31

32 The Francis Enquiry 6 produced a report in February 2013 following the serious failings at the Mid Staffordshire NHS Foundation Trust. This highlighted the failure of the Trust Board to listen to its patients and staff or correct deficiencies brought to its attention. Above all, as the Francis Report highlighted it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities 6. Following on from this the Keogh Report 7 produced in July 2013 was commissioned by the Secretary of State in order to review the quality of care and treatment provided by the 14 hospital trusts with persistently high mortality rates. The trusts exhibited failures in the three dimensions of quality: clinical effectiveness, patient experience and safety as well as failures in professionalism, leadership and governance. The report reinforced the message that an organisation delivering high quality care will be offering care that is clinically effective, safe and delivering as positive an experience as possible for patients 7. The report produced 8 ambitions for improvement. These included progress in reducing avoidable deaths in hospitals via early warning systems and a new national indicator on avoidable deaths. There should also be a drive to share and harness data on quality and to use this in a meaningful way to improve services. Patients, carers and staff should be equal partners in the design and assessment of NHS services including the adoption of real time feedback and transparent reporting of complaints. There should be confidence in the quality assessments made by the Care Quality Commission, which should involve patients and clinicians. Hospitals should be professionally, academically and managerially linked to each other to avoid isolation. Their nursing staff levels should reflect the caseload and severity of their patients with particular attention to out of hours operations. Young doctors should be harnessed as the leaders of tomorrow and there should be a focus on ensuring that staff are happy and engaged 7. The Berwick Report 8 produced in 2013 reviewed the accounts of Mid Staffordshire and the recommendations of the Francis Report. It was focused upon improving the safety of patients throughout the NHS. The report identified a number of problems including incorrect priorities, diffused responsibility, fear and the failure to recognise warning signals, including the concerns raised by both patients and their carers. The report noted a number of issues which the system needed to address. At its focus was the need for the NHS to recognise that a systematic change was required and that a culture of blame needed to be abandoned. It reasserted the primacy of working with patients and their carers and to focus above all else on the importance of better care and to use quantitative targets with caution. It highlighted the need for transparency and safety in our working and with clear lines of responsibility. It reinforced the need for continuous development of staff to ensure quality improvement control and planning and a replacement of fear with a culture of pride and joy for those that work in the NHS 8. 32

33 The report produced 10 recommendations. These included an ethic of learning, transparency and a focus on quality of care in general and patient safety in particular at the top of all leaders priorities. It recommended that patients and their carers be present and involved in all levels of healthcare organisations and should be an essential asset in monitoring safety and quality of care. Staff need to be invested in and be present in appropriate numbers and supervisory and regulatory systems should be simple and clear Standards for Mental Health Service Provision Impacting on Medium Secure Units In addition to the wholesale recommendations for change in the landscape of the NHS were documents focusing specifically on mental health. In 2009 Lord Bradley s review of People with Mental Health Problems or Learning Disabilities in the Criminal Justice System 9 was published. The independent review, commissioned by the Ministry of Justice identified the overrepresentation of people with mental health problems and learning difficulties within the criminal justice system and it proposed 82 recommendations to deal with this. In particular it proposed the establishment of Criminal Justice Mental Health Teams to divert vulnerable people from police stations, courts and prisons into the mental health system. It also called for a 14 day maximum transfer period for acutely unwell prisoners to hospital and the NHS to provide mental health services within police stations 9. Four years after the release of the Bradley Report the Sainsbury Centre for Mental Health produced a follow up report Black and Minority Ethnic Communities, Mental Health and Criminal Justice 10 which focused on the needs of Black and Minority Ethnic (BME) communities, who had been underrepresented in the original report. The report identified five components to engagement with BME communities: cultural competence, person-centred intervention, holistic engagement, mentoring and serviceuser involvement and working in partnership 10. In 2011 the Sainsbury Centre for Mental Health produced Pathways to Unlocking Secure Mental Health Care 11 which reviewed the pathways into and through secure mental health services. The reports identified barriers to throughput including block purchasing of beds by commissioners, a lack of clearly defined eligibility criteria for medium secure services and differences in the direction of flow between people with a mental illness diagnosis as opposed to a personality disorder. The report came up with a number of recommendations. These included the development of a framework of guidance and quality standards for secure services to ensure equitable access to all tiers nationwide. It also recommended a focus on pathways and outcomes, with particular reference to step down and community services which would require appropriate adjustments in investment. It advised that duplicated assessments should cease and where appropriate a single assessment should allow timely access to secure services. In addition, clear service specifications should be developed for all groups of secure patients 33

34 including women, people from BME and those with learning difficulties. It advised better links between mainstream psychiatric services, secure services and the prison estate. Feedback from patients should be harnessed to measure quality and performance as well as aggregating performance data to form a national secure service patient data set. It advised the establishment of shared learning networks to support the developments and implementation of guidance and quality standards and a focus on the Recovery approach across the secure care pathway 11. The Sainsbury Centre for Mental Health released Implementing Recovery: A methodology for organisational change 12 in This was the third in a series of papers proposing a move towards a recovery orientated approach in mental health services as adopted by a number of countries including Australia, Zealand, Ireland and USA. The papers proposed 10 key organisational challenges for implementing recovery. It asserted the need to change the nature of day to day interactions and the quality of these experiences. To deliver comprehensive user led education and training programmes and to establish recovery education units and for organisations to embrace a culture of recovery. It recommended increasing personalisation and choice, to redefine user involvement and change the approaches to risk assessment and management. Finally it promoted supporting staff to support the recovery model and to focus on opportunities for building a life beyond illness 12. The National Institute for Health and Care Excellence produced the Quality standard for service user experience in adult mental health 13 in December This built upon the recommendations from the Darzi Report for compassion, dignity and respect 1 and the 2010 Government White Paper Equity and Excellence: Liberating the NHS 4 that more emphasis needs to be placed on improving patients experience of NHS care which should be addressed when considering service development. It reinforced the focus on the patient voice when improving quality in healthcare provision. It defined 15 quality statements which were considered when reviewing MSU standards. These were: feeling optimistic about care, empathy dignity and respect, shared decision making and self-management, continuity of care, using views of patients to monitor and improve services, access to services, information and explanations, care planning, crisis planning, assessment in crisis, inpatient shared decision making, contact with staff on wards, meaningful activities on wards, using control and restraint and compulsory treatment and combating stigma 13. In January 2014 the Department of Health produced, Closing the gap: priorities for essential change in mental health 14. This provided 25 recommendations to facilitate short term change in mental health provision in order to bridge the gap of the longer term changes which were outlined in the 2010 document No Health Without Mental Health 15. The 2010 document proposed that mental health should have equal priority to physical health, discrimination towards mental ill health should be tackled and that all people who require access to mental health services should have this in a timely way. Despite some changes the government was aware that provision of mental health care remains patchy and support is not being provided in a timely or convenient way. 34

35 Their 25 recommendations aim to bring about faster change and include waiting time limits for mental health services, high quality local services reflecting local need, increased choice for patients, funding for effective services and a reduction in the use of all restrictive practices. Better integration of physical and mental healthcare at every level, a focus on employment and the introduction of national liaison and diversion services for offenders 15. Following on the need to be more explicit about outcomes was the development of My Shared Pathway 16, a branch of the National Secure Services QIPP programme. It focused on patient outcomes in order to progress them through secure services. It aimed to give patients more choice and responsibility and ensure that they remain in secure services for not a day more 16 than they need. It also highlighted the need to make recovery as important as security. Additional information regarding security was produced by the Department of Health s 2010, SEE THINK ACT 17 document which highlighted the importance of relational security. It focused on the interdependence between care and security and the vital role that all staff working in secure environments need to play. Alongside this the Department of Health also produced an Environmental Design Guide for Adult Medium Secure Services 18 in 2011 which outlined the principles and practice for a safe therapeutic environment. 3. Standards and Literature Relating to Secure Mental Health Services The Quality Network for Medium Secure Units produced the first standards for medium secure units in In the same year the Department of Health also published the Best Practice Guidance: Specification for adult medium-secure services 20 in collaboration with Health Offender Partnerships. This detailed document built upon the Department of Health s Standards for Better Health (revised 2006) 21 and listed quality principles built into seven areas: Safety, Clinical and Cost Effectiveness, Governance, Patient Focus, Accessible and Responsive Care, Care Environment and Amenities and Public Health. NHS England produced a standard contract for medium and low secure mental health services for adults in This provided detailed guidance regarding an integrated, recovery based pathway through secure care. It detailed preadmission assessment (including risk needs), clearly defined therapeutic goals developed early on in admission, specialist assessment and treatment of mental health and risk, supporting recovery and rehabilitation linked to outcomes through engagement and selfmanagement, use of the CPA approach, effective clinical governance and services tailored to individual s needs (including BME and women) 22. Key service outcomes identified included patient and carer satisfaction and minimised levels of adverse incidents and complaints. The National Outcomes Framework provided the basis of all secure services outcomes and the reviews were conducted by the Care Quality 35

36 Commission and the Quality Network of the College Centre for Quality Improvement. My Shared Pathway 16 is still evolving; however the NHS England document 22 recommended that services should seek to demonstrate individual s progress according to the 8 outcome areas as defined within the Outcomes, Plans and Progress documentation. These 8 areas are: my mental health recovery, stopping my problem behaviours, getting insight, recovery from drug and alcohol problems, making feasible plans, staying healthy, my life skills and my relationships. Alternative frameworks to map progress through services include Milestones to Recovery 23 (MTR: Holloway 2009) which has helped identify different stages on the MSU pathway and identified therapeutic behaviour as a significant identifier of progress through the MSU and current behaviour helping to predict future aggression. The target length of stay for medium secure units was originally 18 months to two years 24 and there is an increasing emphasis on moving patients through services. Recent studies have identified that a proportion of patients spend considerably longer than this in secure care and have needs requiring longer term rehabilitation in perhaps lower levels of security. The findings from Jaques et al (2010) 24 in their review of long-term care needs in male medium security was that 21% of the population they reviewed had spent over five years in medium security 24. Factors such as co-morbidity, treatment resistance and institutionalisation were identified as contributing to their increased length of stay. It was also noted that only a fifth of this group attended their full rehabilitation programme, highlighting the difficulties with engagement and ultimately pathways through services 24. Shah et al (2011) 25 also looked at factors associated with length of admission at a medium secure forensic psychiatric unit. Their study concluded that patients detained under hospital orders, with an index offence of moderate severity, on restriction orders and with multiple previous admissions and a psychotic disorder tended to stay over 2 years 25. These factors were related to the treatability of their illness as opposed to the risk of violence. Brown & Fahey (2009) 26 also identified restriction orders as a factor resulting in extended length of stay. Good quality evidence for interventions in medium secure units remains weak with a reliance on anecdotal evidence, case series and surveys. Given that the purpose of being in a medium secure unit is focused on treatment of mental illness and co-morbidities it is perhaps concerning that more robust studies examining these treatments are not available. It was noted that patients in secure settings tend to be complex and require a range of interventions across a number of domains 27. This makes assessment of interventions complicated and is perhaps one of the reasons why there remains a dearth of literature in this area. 36

37 With an emphasis on movement through services, rehabilitation as well as public protection we reviewed the literature on the effectiveness of risk assessment tools 28, 29 and outcomes following discharge. Standard risk assessment tools such as the HCR-20, Structured Assessment of Protective Factors (SAPROF) and Short Term Assessment of Risk and Treatability (START) and HONOS secure are recommended. The development of additional tools including the Medium Security Recidivism Assessment Guide (MSRAG) (Hickey et al, 2009) 30 which are specifically aimed for a medium secure population should be noted for future development. Coid et al (2007) 31 examined the rates of readmission of patients discharged from forensic services compared with general services. Sahota et al (2010) 32 compared outcomes for patients discharged from a medium secure unit and found that significantly more women than men were readmitted to any psychiatric unit during follow up. Previous inpatient stays and not having a diagnosis of a psychopathic disorder were also associated with readmission. Overall rehospitalisation rates remained high. The risk of recidivism in medium secure patients was more difficult to study and required longer life time cohorts. In its most simplistic terms the greater the number of risk factors a patient has the higher the risk of reoffending. Studies indicated that 10 years after discharge nearly half of patients discharged from medium secure services will have received a conviction and approximately one in seven for a serious or violent offence. Those committing the serious offences require further study and may contain specific risk factors. Further investigation is required to better understand these subgroups and to target them more effectively. It is clear that there is a need for continuing reassessment of standards relating to the provision of medium secure services. This is relevant in the constantly changing climate of healthcare provision and specifically, the development of secure pathways. The evidence for specific interventions, particularly related to treatment efficacy and long term recidivism remains weak however it is important to review key documents in order to maximise the quality and safety of existing services. 37

38 References: 1 Department of Health (2009a) High Quality Care for all: NHS Next Stage Review 2 final report Lord Darzi. London. DH The NHS Constitution: The NHS belongs to us all (2013) ( 3 Department of Health (2008) A High Quality Workforce: NHS Next Stage Review. London: DH 4 Department of Health (2010) Equity and excellence: Liberating the NHS. 5 London: DH Department of Health National Outcomes Frameworks to The Francis Report (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry. Executive Summary. 7 Keogh, B. (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. National Health Service 8 Berwick, D. (2013) A Promise to Learn A Commitment to Act. Improving the Safety of Patients in England. National Advisory Group on the Safety of Patients in England 9 Department of Health (2009b) Lord Bradley s review of people with mental health problems or learning disabilities in the criminal justice system. London. Department of Health 10 Sainsbury Centre for Mental Health (2013) The Bradley Commission. Briefing 1: Black and Minority Ethnic Communities, mental health and criminal justice. London. Centre for Mental Health 11 Sainsbury Centre for Mental Health (2011) Pathways to unlocking secure mental health care. London. Centre for Mental Health 12 Sainsbury Centre for Mental Health (2009) Implementing Recovery: A methodology for organisational change. London. Centre for Mental Health 13 Quality standards for service user experience in adult mental health. (2011) NICE Quality Standard 14. National Institute for Health and Care Excellence 14 Department of Health (2014) Closing the gap: priorities for essential change in mental health. London. DH 15 Department of Health (2011) No Health without Mental Health. London. DH 16 National Secure Services QIPP Programme, My Shared Pathway (2012) 17 Department of Health (2010) See, Think, Act: Your Guide to Relational Security. London. DH 18 Department of Health (2011) Environmental Design Guide: Adult Medium Secure Services. London. DH 19 Royal College of Psychiatrists (2007), Quality Network for Forensic Mental Health Services, Standards for Medium Secure Units (CRTU 004) 20 Department of Health (2007) Best Practice Guidance. Specification for Adult Medium Secure Services. Health Offender Partnerships. London. DH 38

39 21 Department of Health (2006) Standards for Better Health. London. DH 22 NHS Standard Contract for Medium and Low Secure Mental Health Services (adults) (2013). NHS England 23 Doyle, M., Logan, C., Ludlow, A., Holloway, J (2012) Milestones to recovery: Preliminary validation of a framework to promote recovery and map progress through the medium secure inpatient pathway. Criminal Behaviour and Mental Health 22; Jaques, J., Spencer, S., Gilluley, P (2010) Long term care needs in male medium security. British Journal of Forensic Practice. Volume 12 Issue Shah, A., Waldron, G., Boast, N., Coid, J., Ullrich, S (2011) Factors associated with length of admission at a medium secure forensic psychiatric unit. The Journal of Forensic Psychiatry & Psychology. Vol 22, No. 4: Brown, K & Fahey, T (2009) Medium secure units: pathways of care and time to discharge over a four-year period in South London. The Journal of Forensic Psychiatry & Psychology, Vol. 20, No. 2, Davies, J & Oldfield, K (2009) Treatment need and provision in medium secure care. British Journal of Forensic Practice, Volume 11, Issue 2: Maden T. (2007) Treating Violence: A Guide to Risk Management in Mental Health. Oxford University Press. 29 Sainsbury Centre for Mental Health (2008). Rutherford, M. & Duggan, S. Forensic Mental Health Services; Facts and figures on current provision. London. Centre for Mental Health 30 Hickey, N., Yang, M., Coid, J (2009) The development of the Medium Security Recidivism Assessment Guide (MSRAG): an actuarial risk prediction instrument. The Journal of Forensic Psychiatry & Psychology, Vol 20, No. 2: Coid, J.,Hickey, N. & Yang, M. (2007a) Comparison of outcomes following aftercare from forensic and general adult psychiatric services. British Journal of Psychiatry, 190, Sahota, S., Davies, S., Duggan, C et al (2010) Women admitted to medium secure care: Their admission characteristics and outcome as compared with men. The international Journal of Forensic Mental Health, 9 (2):

40 Appendix 2: Acknowledgements The Quality Network for Forensic Mental Health Services Project Team is extremely grateful to the following people for their time and expert advice in the development of these standards: - Elizabeth Allen - Independent Advisor - Bill Abbott OBE - Independent Secure Services Policy Advisor - Members of the Standards Development Working Group Standards Working Group (see Appendix 3) - Delegates of the Stakeholder Consultation Event 18 March 2014 (see Appendix 4) - Patient Reviewers and Family & Friends Representatives (see Appendix 5) 40

41 Appendix 3: Standards Development Working Group Name Job Title Service Dan Beales Louise Davies Jude Deacon Consultant Forensic Psychiatrist Mental Health & Programme of Care Lead Head of Low Secure Services Fromeside, Avon and Wiltshire Partnership NHS FT Yorkshire & Humber Team, NHS England Oxford Health NHS Foundation Trust Colleen Fahy Nurse Consultant Alpha Hospitals Bury Paul Gilluley Mary Harty Harry Kennedy Jeremy Kenney- Herbert Mat Kinton Consultant Forensic Psychiatrist (Chair) Consultant Forensic Psychiatrist & Associate Medical Director Executive Clinical Director & Consultant Forensic Psychiatrist Clinical Director/Consultant Forensic Psychiatrist Mental Health Act Policy Advisor West London Forensic Service South West London & St Georges Mental Health NHS Trust National Forensic Mental Health Service, Central Mental Hospital Reaside Clinic Care Quality Commission 41

42 Appendix 4: Delegates Stakeholder Consultation Event 18 March 2014 Name Job Title Service Amina Jappie Integrated Clinical Lead Brockfield House Andy Brooker Patient Anju Soni Locum Consultant West London MHT Beverley Humes Bridget Bineham Bridget Clancy Catherine Durkin Family & Friend NHS England Commissioner: Surrey & Sussex Head of Nursing & Patient Experience - Secure Division Presenter NHS England Ashworth Hospital Clare Bingham Clinical Psychologist John Howard Centre Clare Mounce Clinical Ward manager Ravenswood House Collen Fahy Nurse Consultant Alpha Hospital Bury Craig Hart Social Worker Kneesworth House CI Daniel Beales Family & Friends Representative Consultant Forensic Psychiatrist Fromeside Dannie Farrar Senior Nurse Manager Alpha Hospital Bury Dave Hearn Security Team Leader River House Dave King Security Lead Humber Centre Dave Owen Junior Matron Arnold Lodge Dawn Jeffries Director of Clinical Services Thornford Park Hospital 42

43 Denise Cuddy Dr Amit Nigam Dr Christopher Ince Dr Jayanth Srinivas Dr Jude Deacon NHS England Commissioner: London Consultant Forensic Psychiatrist Lead Consultant - Adult Forensic Services Clinical Director Head of Forensic Services NHS England Westminster Forensic Community Service Northgate Hospital Hatherton Centre Oxford Clinic Dr Kaysi Thinn Consultant Psychiatrist Kneesworth House Dr Nicola Phillips Consultant Psychiatrist Northgate Hospital Dr Paul Gilluley Chair of Advisory Group Dr Renata Rowe Consultant Psychiatrist Reaside Clinic Emma Croft Clinical Lead O.T Oxford Clinic Emma Lamb Security Lead Alpha Hospital Bury Gail McCabe Family & Friends Representative Gary Stobbs Unit Manager North London Clinic Geoff Keats Clinical Services Manager Cygnet Stevenage George Popa Security Lead North London Clinic Greg Yates Ward Manager Ty Llywelyn Helen Courtney Modern Matron Humber Centre Hilary Lomas Iain Wilkie Imogen Mortiboys Consultant Occupational Therapist Interim Service Director Secure Division Clinical Services Manager Scott Clinic Ashworth Hospital St Andrew's Birmingham 43

44 Jan Morris Service Development Managers Reaside Clinic Jason Rose Charge Nurse Kneesworth House Joe Murray Corporate Head of Security St. Mary's Hospital John Paradise Learning and Development Officer St Andrew's Northampton John Tynan Patient Safety Manager Calderstones Jonathon Lynch Nurse Consultant Hellingly Centre Laura Wiltshire Regional Lead Social Worker Calverton Hill Lesley Wilson Lorraine Concannon Head of Clinical Effectiveness Security Supervisor St Andrew's Northampton Norvic Clinic Lucy Palmer Senior Programme Manager RCPSYCH Mark Rice- Thomson Hospital Manager Huntercombe Hospital Mark Simon Director of Nursing Alpha Hospital Bury Mary-Ann Doyle Mat Kinton Programme Director National Mental Health Act Policy Advisor NHS England CQC Michael Humes Patient Reviewer Miranda Brabon Murad Kutay Nick Taylor Management & Governance Manager NHS England Commissioner: London Consultant Forensic Psychiatrist Norvic Clinic NHS England Arnold Lodge Nicola Bennett Clinical Service Manager Ravenswood House Nicola Hewson Team Leader, Admisisons Eric Shepherd Services Nicola Macgregor NHS England Commissioner: London NHS England 44

45 Phil Dickinson Ward Manager Wathwood Hospital Rachael Sutton Rebecca Hills Richard Barker NHS England Commissioner: Cheshire, Warrington and Wirral Area Team Care Group Director, Secure and Forensic services Consultant Clinical & Forensic Psychologist NHS England Hellingly Centre Oxford Clinic Rick Fuller Modern Matron Wathwood Hospital Rose Stott Senior Nurse Manager Alpha Hospital Bury Rowena Bennett Sam Antwi- Marful Samudra Sarkar Sarah Heys Sean Mooney Regional Lead Nurse Deputy Service Director Consultant Forensic Psychiatrist Integrated Business Manager Security Clinical Manager Secure Division Calverton Hill River House St Andrew's Northampton - Smyth House Guild Lodge Ashworth Hospital Sheryle Cleave Senior Clinical Nurse St Nicholas Hospital Shirley Wheeler Deputy Head of Operations Edenfield Centre Simon Allen Modern Matron Ty Llywelyn Steve Kenniford Steven Wallace Steven Woolgar Ward Manager (acting) Senior Nurse Manager Director of Policy & Regulation Calderstones Alpha Hospital Bury Partnerships in Care HQ Sue Stewart Integrated Clinical Lead Brockfield House Vanessa Odlin Oxford Clinic Vincent Keep Security Manager Wathwood Hospital 45

46 Appendix 5: Patient Reviewers and Family & Friends Representatives Name Job Title Abdirisak Hussein Patient Reviewer CI Family & Friends Representative Gail McCabe Family & Friends Representative George Cooley Family & Friends Representative Ian Callaghan Jason Feely Margaret Britton Michael Humes Roger Sharp Patient Reviewer Patient Reviewer Family & Friends Representative Patient Reviewer Patient Reviewer Sarah Markham Patient Reviewer Seb Pringle Patient Reviewer Susan Riding Family & Friends Representative Tania Charles Patient Reviewer 46

47 Appendix 6: Project Team Name Job Title Sarah Tucker Programme Manager Sam Holder Deputy Programme Manager LSU Geraldine Murphy Deputy Programme Manager - MSU Megan Georgiou Project Worker LSU Maddy King Rebecca Ryan Emily Lesnik Ilham Sebah Project Worker LSU Project Worker LSU Project Worker MSU Project Worker MSU 47

48 Appendix 7: Glossary Name Job Title CCQI CCTV CPA College Centre for Quality Improvement Closed-Circuit Television Care Programme Approach CPD Continued Professional Development CQC DH LSU MAPPA MDT MSU NHS PDP Care Quality Commission Department of Health Low Secure Units Multi-Agency Public Protection Arrangements Multi-Disciplinary Team Medium Secure Unit National Healthcare Service Personal Development Plans PSD PSID RCPSYCH OT BME QIPP Physical Security Document Procedural Security Index Document Quality Network for Forensic Mental Health Services Royal College of Psychiatrists Occupational Therapy Black and Minority Ethnic Quality Innovation Productivity Prevention 48

49 49

50 50