Cycle 3 Annual Report Low Secure. Quality Network for Forensic Mental Health Services

Transcription

1 Cycle 3 Annual Report Low Secure Quality Network for Forensic Mental Health Services Editors: Renata Souza, Sam Holder, Amy Lawson, Francesca Coll and Megan Georgiou Publication Number: CCQI211 Date: October 2015

2 The Quality Network ran a competition to find a piece of patient artwork to use on the front cover of the Cycle 3 Annual Report. The team would like to thank all of the patients who submitted entries. 1. The winning design on the front cover came from Ollie, a patient from Cheswold Park Hospital. 2. Picture 2 (Blue Still Life) was painted by CM, a patient from Northgate Hospital. 3. Picture 3 was painted by Steve Dodds from Cheswold Park Hospital. 4. Picture 4 (Plants) was painted by a patient from Northgate Hospital. 5. Picture 5 was painted by RM, a patient at Forest Lodge.

3 Contents Preface 5 This Report 7 Overview 10 Introduction 15 Key Themes 24 Recommendations 26 A: Model of Care 28 1: Admission 28 2: Recovery 30 3: Physical Healthcare 32 4: Discharge 34 B: Safe and Therapeutic Environment 36 1: Physical Security 36 2: Relational Security 38 3: Procedural Security 40 C: Service Environment 42 D: Workforce 44 E: Governance 46 F: Equalities 48 APPENDIX A: AGGREGATED DATA 50 APPENDIX B: MEMBER UNITS APPENDIX C: EXAMPLES OF GOOD PRACTICE 63 APPENDIX D: THE REVIEW PROCESS 103 APPENDIX E: PROJECT TEAM 105 APPENDIX F: ADVISORY GROUP 106 APPENDIX G: QNFMHS PATIENT REVIEWERS 108 APPENDIX H: QNFMHS FAMILY & FRIENDS REPRESENTATIVES 108

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5 Preface I am delighted to introduce this report from the Quality Network for Forensic Mental Health Services, summarising the key findings of the third annual peer-review Cycle of 94 low secure units across England, Wales and Northern Ireland. In addition to our core work of the self and peer-reviews, this year the Quality Network ran two focused workshops, one on the role of front line staff in forensic services and the other on ways in which patients and friends and families of those in low secure care can be further engaged in the Quality Network s self and peer-review processes. The outcomes of this activity is summarised in the introduction to this report and underlines the importance that the Quality Network places on patients, family and friends being a central and proactive part of our bottom-up approach to overall quality improvement. The Project Team would like to draw your attention to Appendix C of this report (Examples of Good Practice) which provides a great resource for services to converse about experiences, advise each other and ultimately share best practice about what member services are doing well. I would like to encourage you to contact each other to further strengthen your services and quality improvement. Quazi Haque, Chair Advisory Group 5

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7 This Report This annual report is structured around the six sections of the Standards for Low Secure Services 1. The criteria forming the basis of the review process have been mapped onto the Care Quality Commission s Essential Standards of Quality and Safety 2. This supports services to provide evidence of meeting these standards via participation in the Quality Network s self- and peer-reviews. The body of the report highlights achievements, areas for improvement, and gives examples of solutions to common problems. For anonymity purposes each unit has been assigned a number; the graphs on the following pages have been ordered on the vertical axis by score so it is possible to see where each unit lies in comparison with the lowest, the highest and the average. The average score for each section has also been highlighted on the graphs. Appendix A is a full summary of the extent to which the 94 services met each criteria. How members of the Quality Network for Forensic Mental Health Services can use this report: How well are we doing overall in comparison with the Quality Network? Your unit s local report provides you with a summary of the number of criteria met, partly met and unmet, which then gives an average score for each area. These averages enabled us to obtain a measure of your unit s overall performance for each section of the criteria. Average scores for Cycle 3 are detailed in the key findings and in Appendix A so you can immediately see how well you are doing compared with the other units in the Quality Network. Each member has also been assigned a unique team number so that you can use the graphs in this report to compare yourselves with the rest of the Quality Network. What are the key areas of variance within the Quality Network? The key findings highlight areas identified within each section that best differentiate services from one another, and also those criteria considered to be critical to the quality of care provided. How can we identify other services that could provide advice or support on specific areas of service development? A summary of good practice that peer-review teams have identified during reviews is presented in Appendix C to aid information sharing amongst the Quality Network s members. Acknowledgements: The Project Team gratefully acknowledges: The staff in member units who organised, attended and received peer-reviews. Patients in member units who took part in the peer-review of their unit. The Patient Reviewers and Family and Friends Representatives for their continuing work with the Quality Network. The Advisory Group (see Appendix F) for their continuing support and advice

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9 On average, services fully met 90% of low secure criteria No service met less than 69% of the criteria in Cycle 3 9

10 Overview This section provides an overview of the findings from the Cycle 3 review period. Figure 1 gives the average percentage of met criteria in each standard area, and Figure 2 details the total percentage of met criteria across all the units. Figure 1: Average Percentage of Met Criteria per Section On average, services were found to be compliant with 90% of criteria across the standard areas. As the graph above highlights, Admission, Physical Healthcare, Discharge and Procedural Security are the areas in which units scored most highly. On average services met 96% of the criteria in these areas. Further to this, it is commendable that services were found compliant with 91% of the Workforce and Recovery criteria, 89% of Physical Security and 87% of Equalities criteria. Service Environment is an area for ongoing improvement for our low secure members, with only 78% of criteria being met in this area. This is due to services struggling to fully meet standards in relation to patient controlled observation panels in bedroom doors, separate child visiting facilities, and lines of sight, with scores of 57%, 49% and 40% fully met respectively. Figure 2, shows the average percentage of fully met criteria across all standard areas for all participating low secure services. 10

11 Data Label Figure 2: Total Percentage of Met Criteria across All Units Average 90% Percentage of Met Criteria 11

12 % Met Figure 3: Comparison of Core Criteria between Cycles 1, 2 and Cycle 1 Cycle 2 Cycle This graph shows the average percentage of fully met criteria in the ten standard areas covered by the low secure standards over the last three Cycles. It is pleasing to see that there have been improvements across the board this Cycle. Overall, since the low secure network was established, there have been improvements in a range of standard areas. Standard area % increase Cycle 1-3 Admission 2 Recovery 4 Physical Healthcare 1 Discharge 1 Physical Security 5 Relational Security 6 Procedural Security 3 Service Environment 5 Workforce 1 Equalities 2 It is highly commendable that, over the last three Cycles, there has been an 18% increase in services seeking and taking into account the views of patients and carers in the designing, planning and improvement of services. An additional 14% of services now have an implemented policy setting out the consultation and involvement of carers in the care provided. There are some criteria however, for which we have seen a year on year decrease in the percentage of services able to meet them. There has been a 12% decrease in the 12

13 number of services able to provide patients with meals which are of a high quality, 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. Notably there has also been a 7% decrease in the number of services who have a cohesive multi-disciplinary team with the capacity and capability to meet the needs of their patients. 13

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15 Introduction The Quality Network for Forensic Mental Health Services was set up in 2006 at the College Centre for Quality Improvement. The network was initially set up for medium secure services. For the past nine years it has been honing and consolidating structures and processes. In , the peer-review process was extended to low secure services and the third annual Cycle for these services is now complete. This report summarises the aggregated results of the reviews undertaken across 94 low secure units (232 wards) in England, Wales and Northern Ireland during Using a multi-disciplinary approach, the Quality Network facilitates quality improvement and change through a supportive peer-review process. The Quality Network serves to identify areas of good practice and achievement, as well as areas for improvement by promoting a culture of openness and enquiry between peers. A fundamental principle of the Quality Network is that patients, frontline staff and family and friends of patients are an integral part of sustainable quality improvement; this is reflected in the structures and processes used by the project. Member units use the results of reviews to develop action plans in order to achieve year on year improvement. They are also encouraged to share their final results with key stakeholders, including commissioners, CQC, health and local authorities, those making referrals to their services and local patient and family and friends groups. What does the Quality Network for Forensic Mental Health Services do? The Quality Network s activities include: Developing and applying standards for forensic mental health services through a system of self and external peer-review; Producing reports for participating services that highlight areas of achievement and areas for improvement in relation to service standards; Providing a national benchmarking service to allow services to compare their activity with other services; Facilitating information-sharing about best practice between members of the Network; Organising workshops to support services to share information and troubleshoot on shared problem areas; Supporting routine data collection, e.g. regarding clinical and cost outcomes; Promoting patient and family and friends involvement at all stages of the review process. A full description of the Quality Network s review process and activities can be found in Appendix D. 15

16 Responding to Recommendations from Cycle 2 The Quality Network made three recommendations in response to the key areas for improvement during peer-reviews in Cycle 2 ( ). For each recommendation, the Quality Network team organised opportunities via various media to share and implement good practice in these areas. These included newsletters and workshops for services to learn from each other outside of the core peer-review process. This work has been disseminated across the Network and posted on the website 3. Recommendation 1: Patient Involvement Patient involvement was identified as a challenge for many services. The Quality Network recommended prioritising the collection of feedback from patients ensuring this informs service development and that this is fed back to patients. The Quality Network also aimed to ensure patients are involved in all aspects of the CPA process, including reading and helping write the report, prior to and after the meeting. This provides patients with the opportunity to add their views and be included in all parts of the CPA meeting. The Quality Network hopes to support services to look at other ways to involve patients within the service. In response to this recommendation the Quality Network held an event on 16 April 2015, which focused on engaging patients. The workshop was well attended by patients and staff and provided a platform for the sharing of good practice and troubleshooting problems. It looked at ways of increasing patients involvement in their care within secure services and also in the quality improvement work of the Quality Network itself. Recommendation 2: Family and Friends Involvement Involving family and friends was also found to be a challenge. The Quality Network recommended that services develop regular family and friends groups and hold open days where family and friends of patients can visit the ward. The Quality Network also recommended that services create a directory of carer advocacy services to signpost family and friends to their local advocacy service. In addition it was recommended by the Quality Network that services review ways, in consultation with family and friends, to provide support sessions and to signpost and help family and friends to access psychological support through their own GPs. Finally, the Quality Network recommended nominating a member of staff at a service to be the Family and Friends Coordinator. In response to this recommendation the Quality Network held an event on 16 April 2015 focusing on engaging family and friends. The workshop was well attended by family and friends representatives, staff and patients. The Quality Network also produced a themed newsletter for sharing good practice on family and friends involvement in low secure services. This can be found on the webpage: mentalhealth/lsu/news discussiongroup.aspx

17 Recommendation 3: Service Environment Service environment was found to be a challenge. The Quality Network aimed to support services to make best use of the space available to them, such as multi-purpose spaces which can be booked and suitable materials provided for that use i.e. religious texts or other artefacts. The Quality Network also recommended that services involve patients in the design and decoration of newly developed spaces as well as involving patients in the identification of blind spots when considering space management or the installation of mirrors or CCTV. In response to this recommendation the Quality Network published a themed edition of the elsu newsletter looking at facilities within low secure services to facilitate the sharing of good practice and information across the Network. This can be found on webpage: mentalhealth/lsu/news discussiongroup.aspx. 17

18 Patient Involvement The Quality Network for Forensic Mental Health Services has continued to develop and as a result, increased patient involvement during Four additional Patient Reviewers were recruited, taking the total number of Patient Reviewers to ten during this Cycle. Table 1 shows how the percentage of peer-review teams including Patient Reviewers has increased since Cycle 1. Table 1: Cycle 1 Cycle 2 Cycle 3 81% 87% 88% Each year the Quality Network has advertised across member services for Patient Reviewers to apply for the role. There is a job description and personal specification and applications are considered and shortlisted by the Project Team on this basis. Candidates who are shortlisted are then invited to attend an interview with members of the Quality Network Project Team and an existing Patient Reviewer. The Quality Network accepted applications from patients who are at various stages in their recovery. Some patients need to be escorted, others have been discharged from hospital and are living in the community and some have been recalled to hospital whilst being a Patient Reviewer. Part way through Cycle 3 the decision was made that Patient Reviewers who are living independently in the community would be eligible for overnight stays as appropriate for specific peer-reviews. A Patient Reviewer Clinical Advisor supports the Project Team in their work with Patient Reviewers and each Patient Reviewer is supported by a named member of the Project Team. This support includes induction training, annual contingency planning meetings (to clarify roles, risk and pre-empt any problems), annual review meetings, regular interim support and business meetings, and day-to-day telephone support around arrangements prior to peer-review visits. The Project Team are expected to: Coordinate the peer-review timetable and provide Patient Reviewers with this information. Provide support before and during the peer-review visits, e.g. the provision of peer-review pack information. Book travel to peer-reviews, Advisory Groups, support meetings, the Annual Forum and other events. Organise quarterly group support meetings. Provide weekly telephone support. Provide annual review meetings. Liaise with Patient Reviewers Care Coordinators. 18

19 Family and Friends Involvement At the beginning of Cycle 3, the Quality Network expanded the Friends and Family team by two. This is due to the growing number of services signing up to the Low Secure Quality Network along with the recommendations from the previous Cycle to involve family and friends of patients. In Cycle 3, the role of our Family and Friends Representatives has included: 1. Conduct telephone conferences with the family and friends of patients as part of the self-review process. 2. Contribute to newsletters. 3. Consult on standards. 4. Sit on the Advisory Group. 5. Present at workshops and events. Out of 94 low secure services, 85 services had calls take place with a family member, or friend of a patient from their service. This is an increase of 22% from Cycle 2. The Representatives have been significantly involved in the events of Cycle 3, presenting at most of the events held by the Network this year, including a workshop on the role of frontline staff in secure services and the Low Secure Annual Forum Most notably, three of the Family and Friends Representatives co-facilitated and presented at a workshop in April 2015; Engaging Patients, Family and Friends in the Quality Network s Review Process. The presentations were powerful and thought-provoking, and raised many important areas for discussion. As of Cycle 3, we promoted two of our Representatives into lead roles due to their commitment to the Quality Network and their passion in promoting the involvement of family and friends in secure services. This role entails taking a lead on induction training and offering support by telephone to new Representatives, taking a lead on presentations and coordinating the involvement of other Representatives, for instance in developing new materials. Furthermore, we have two Family and Friends Representatives that sit on the Quality Network s Advisory Group. They provide updates on the current involvement of family and friends within the Network and they suggest ways of how this can be developed. A member of the Project Team supports the Family and Friends Representatives in carrying out their roles. This support includes a comprehensive induction and twice yearly review meetings, as well as telephone and contact. Guidance and practice sessions are also offered to those presenting at events or submitting newsletter articles. 19

20 Cycle 3: A total of 232 wards across 94 low secure units participated in the third annual Cycle. The self-review tools were completed by member units between July 2014 and April 2015, and the external peer-reviews were undertaken between September 2014 and May Out of the 94 member services reviewed 38 cater for women. These services were also reviewed against the Standards and Criteria for Women in Medium Secure Care as well as the Low Secure Criteria of the services provide care for patients with learning disabilities and were reviewed against the Standards for People with Learning Disabilities in Medium Secure Care 5. Finally two out of the 94 services reviewed cater for deaf patients and were reviewed against the Standards for Deaf People in Medium Secure Care 6. The services catering for women, learning disabilities and deaf patients were reviewed against the low secure standards as well as the medium secure specialist standards for these specific areas as it was found that the standards being reviewed were directly transferable to low secure settings. Approximately 342 staff participated as peer-reviewers, interviewing over 1000 staff and 560 patients in low secure units. Patient telephone conferences were undertaken as part of the self-review at 92% of the member units and 88% of peer-review teams included a Patient Reviewer. Figure 4: Distribution of Units This figure shows the distribution of participating units across England, Wales and Northern Ireland. 1% 1% England Northern Ireland Wales 98% 4 In the appendix all criteria marked with a w denote the standards for women and the standards can be found on our website at: 5 In the appendix all criteria marked with LD denote the standards for Learning Disabilities in Medium Secure Care and the standards can be found on our website at: 20Care%20-%20final.pdf. 6 In the appendix all criteria marked with a Deaf denote the standards for deaf people in medium secure care and the standards can be found on our website at: e.pdf. 20

21 Figure 5: Proportion of NHS and Independent Sector Units 44% 56% NHS Independent Figure 5 shows the proportion of NHS (and other regional Health Boards) and Independent sector units who are part of the Quality Network. Figure 6: Proportion of Stand-alone LSU and Combined MSU & LSU Peer-review Visits 44% 56% LSU Same site This figure shows the proportion of reviews which are carried out for stand-alone low secure services and those carried out as part of a same site review where a service has both low and medium secure services. 21

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23 Key Themes Services met 96% of standards within the Admission, Physical Health Care, Discharge and Procedural Security sections. 23

24 Key Themes This section outlines the key issues that have emerged from the Cycle 3 reviews. It recommends actions that units can take in response to the areas of improvements raised and outlines the measures the Quality Network for Forensic Mental Health Services will take to support services. Equalities Patient involvement continues to be an ongoing challenge for many of our services. It was highlighted as a key issue in Cycle 2 and identified as a key focus for the Quality Network during Cycle 3. The Quality Network attempted to streamline this focus by gathering patient feedback through telephone conferences and sharing policies with visiting peer-review teams to draw their attention to this focus and share best practice. Despite the emphasis, and support, from the Network to member services, patient focus and pathways was continually raised as a challenge by the review teams. As many as 34% of our member services were unable to fully meet the standard around providing fresh food to patients that offers choice, is nutritionally balanced and is portioned correctly. This also includes services not being able to adequately offer patients alternatives when there are dietary or cultural requirements. The Quality Network would like to continue to encourage services to further grow their self-catering resources and accessibility for patients. Another area of challenge for member services in Cycle 3 was the use of feedback from patients and carers to improve the quality of the service. With many services suitably seeking and collecting the feedback of their patients and friends and families, a remainder of 21% of services are not utilising this information sufficiently to make changes to their services. In some cases this was a matter of communicating how patient and carer feedback has been used to make changes back to those individuals in a succinct way. As of Cycle 4 the Quality Network will be introducing online questionnaires to reach a wider cohort of individuals to gain feedback and this will be used to further support services in the improvements they can make when communicating with their patients and friends and families. In conclusion, the Quality Network has worked to support services with the areas raised above and in April 2015 a workshop was held based around the idea of engaging patients, friends and family in the Quality Network s self and peer-review process. The event was made up of a mixture of presentations, the sharing of personal accounts from Patient Reviewers and Family and Friends Representatives, as well as small group facilitated discussions. The event was well attended by staff and patients from across a wide range of member services. Service Environment During Cycle 3, review teams raised a number of issues around service environment and facilities. Almost half of member services were identified by their visiting peer-review teams to have issues with lines of sight in patient areas and on the wards. Whilst it is recognised that this issue is largely to do with the design, footprint and age of buildings it continues to be an important area of focus with an acknowledgment made by the Quality Network to incorporate innovative ways of supporting services with this. In addition, another theme that was raised throughout Cycle 3 with regard to environment and facilities is the provision of space for visiting purposes. It was found that 51% of 24

25 member services are unable to offer satisfactory space for child visits. This includes having a separate and appropriately furnished room for these visits to take place. Moreover, space for the practicing of faith was identified as a challenge with 37% of services not providing a multi-faith room available for patients to use. Again, there is recognition by the Quality Network that the theme of environment and facilities is limited by a service s building design and capacity for change. However, a themed edition of the low secure newsletter is due to be published to provide added insight and support to member services. Workforce With 36% of services not providing adequate supervision for members of staff on a monthly basis, this was highlighted to be an area of challenge for Cycle 3. The Quality Network would like to encourage and further support member services with their responsibilities to members of staff and to look at ways in which handovers, informal supervision, reflective practice and other forms of supervision can be used to strengthen this area. However, having said this, the aggregated data for Cycle 3 showed 97% of services regularly monitoring and auditing their staff uptake of supervision. The discrepancy between the two standards surrounding staff supervision emphasises the need for this to be an area of focus in Cycle 4. 25

26 Recommendations The following recommendations address the issues identified from the key themes previously discussed. T he Quality Network has outlined how it plans to support services in addressing these issues over the coming Cycle. Recommendation 1: Equalities Prioritise the collection of feedback from patients and family and friends ensuring this informs service development and that this is fed back to patients and family and friends. Encourage services to review other ways in which issues with the provision of food can be managed through self-catering or improving their food suppliers. Ensure patients are involved in designing menu choices and options. Support services to look at other ways to involve patients within the service. Recommendation 2: Service Environment Encourage the sharing of best practice to action issues relating to lines of sight and the difficulties that are presented by this due to the Physical Environment. Assist services in identifying separate and appropriate spaces for visiting, in particular child visits. Continue to assist services in the provision for space to enable patients to practice their faith in a dedicated and appropriate place. Recommendation 3: Workforce Work with services to review the lack of staff supervision taking place on a monthly basis across a significant number of our member services. Encourage services to offer other types of supervision and support them to look at how these can be embedded. Assist services to define the discrepancy between poor staff uptake of supervision and the successful ways in which services are monitoring and auditing supervision. What will the Quality Network for Forensic Mental Health Services do? Hold a number of themed workshops. Publish quarterly themed newsletters. The first edition of Cycle 4 will be published in September Continue to promote the LSU discussion forum to facilitate further discussions and dissemination of information. 26

27 Key Findings Key findings from each section have been highlighted. This includes areas of achievement and areas for improvement, as well as solutions and examples of good practice in each section from some of our member units. A graph showing the percentage of met criteria across all units is also provided for each section; this shows the units in order of achievement and provides the average score, allowing units to benchmark themselves against each other. 27

28 A: Model of Care 1: Admission Key Findings Number of criteria in Admission: 3 Average percentage of criteria fully met: 96% Range: % Achievements 100% of services ensure patients have an initial care plan in place within 24 hours of admission. 100% of services have a clear criterion for admission to and transfer and discharge from the service which is communicated with commissioners. This also includes 100% of services ensuring that the discharge procedures are operated in line with pathways. Areas for Improvement 16% of services do not meet the standard for all patients having an identified care coordinator or link person for the facilitation of ongoing links to the community and further support from their home area. Solutions Ensure all patients have a link person from their home area who is in regular contact with him/her and is invited to attend meetings throughout the patient s pathway. Ensure care coordinators are involved in the facilitation of ongoing links and the progress of patients' care pathways from admission through to discharge. Examples of Good Practice Cygnet Hospital Bierley: Staff visit patients prior to admission and give them an information booklet about the service. Wolfston House: Previous patients return to the service to co-facilitate groups and present on their personal testimonies of recovery to the whole patient group. Tony Hillis Unit: Community practice nurses and social workers from the patient s home area are invited to CPA meetings and ward rounds to maintain links with the community throughout a patient s pathway. North London Clinic: The service uses a buddy system for new patients. An existing patient will call the new admission and be present on the day of the visit to the ward to ensure any new admission has a friendly face on arrival. 28

29 Data Label Figure 7: Percentage of met criteria for Admission Percentage of Met Criteria Average 96% 29

30 2: Recovery Key Findings Number of criteria in Recovery: 18 Average percentage of criteria fully met: 91% Range: % Achievements 98% of services offer a variety of recreational activities and occupational facilities with 99% of services having a structured activity timetable in place in which patients engage. 98% of services take a recovery focused approach to addressing accommodation, employment and learning needs, including meaningful social contact and mainstream activities. 95% of services encourage and allow patients to negotiate with their care coordinators who they wish to invite to their CPA meetings. Areas for Improvement 24% of services do not have appropriate provisions for patients requiring a period of engagement and treatment away from the main patient group. 22% of services do not meet the standard for showing patients a copy of their final draft CPA report after the meeting. Solutions Ensure that all wards have access to a seclusion facility or de-escalation area without having to access another ward. Work with patients to ensure reports are completed and discussed one week before their CPA meeting. Ensure that patients are provided with written feedback after their CPA meetings and that they are provided with an opportunity to add their views. Examples of Good Practice Cheswold Park Hospital: The service has formed a patient and staff band who practice regularly and perform. Kemple View: The CPA process focuses on areas of recovery such as, relapse prevention, early warning signs, support networks and self-harm reduction. Kneesworth House Hospital: The service encourages patients to choose from a range of recovery tools available on the wards that best suit them and their recovery outcomes. St Andrew s Healthcare CAMHS: The education provision at the service achieved outstanding in their most recent Ofsted inspection. The centre also hosts educational trips including the Harry Potter Studios and war themed days out. 30

31 Data Label Figure 8: Percentage of met criteria for Recovery Average 91% Percentage of Met Criteria 31

32 3: Physical Health Care Key Findings Number of criteria in Physical Health Care (inclusive of two female specific 8 criteria and one criterion for services with deaf patients): Average percentage of criteria fully met: 96% Range: % Achievements 100% of services routinely carry out full assessments of patient s physical and mental health needs. 95% of services provide general health promotion activities including screening, dietary advice and opportunities to exercise. 92% of services support female patients in accessing primary and secondary screening programmes. Areas for Improvement 13% of services are unable to offer female patient s access to a female General Practitioner. 5% of services do not have comprehensive access to a range of primary healthcare services. Solutions Review the need to establish a service level agreement with local primary care services. Look into registering all patients with a local General Practitioner service. Consider registering all patients with a local gender appropriate General Practitioner to ensure that appropriate screening is monitored. Examples of Good Practice Cygnet Hospital Blackheath: The service has a voucher incentive programme used to encourage patients to engage in exercise. Southview: Patients have a weekly Modified Early Warning Score (MEWS) as part of their physical health checks. St Magnus Hospital: The service runs a balance improvement group and a falls clinic. The Spinney: There are many health initiatives visible at the service, including the traffic light system at the shop which monitors the amount of unhealthy foods patients can buy at any one time, as well as the successful Shape Up, Trim Down programme. 32

33 Data Label Figure 9: Percentage of met criteria for Physical Healthcare Percentage of Met Criteria Average 96% 33

34 4: Discharge Key Findings Number of criteria in Discharge: 3 Average percentage of criteria fully met: 96% Range: % Achievements 100% of services determine readiness for discharge of all patients based on multidisciplinary assessments. The multi-disciplinary team supports patients to develop and maintain links with community-based organisations in 99% of services. Areas for Improvement A total of 10% of services are unable to fully involve social workers, care coordinators and offender managers in care planning processes for treatment in their services, as well as post discharge follow-ups under Section 117 arrangements. Solutions Ensure all patients have involvement from social workers in their care planning and approach to discharge. Consider recruiting an in-house social worker who can actively work with the multi-disciplinary team to help with care planning processes and post-discharge follow-up. Examples of Good Practice 4 Bowlers Green: The service employs a liaison nurse who works closely with home area care coordinators and those working as the next point of care to ensure smooth, effective discharges. Northgate Hospital: Recovery and Outcomes meetings provide support for patients to develop and maintain links with the community and aid social interactions. Rathbone Low Secure Unit: The service has a Bridge Builder who facilitates links with the community, providing the patient group with access to a range of activities including the Recovery College. Bade Ward: Bade Ward uses their own forensic community team and step-down services where possible to prevent delays in discharges. Wells Road Centre: The service has good links with MAPPA and the local Victim Liaison Team, parole processes and the forensic community team for effective and long lasting discharges. 34

35 Data Label Figure 10: Percentage of met criteria for Discharge Percentage of Met Criteria Average 96% 35

36 B: Safe and Therapeutic Environment 1: Physical Security Key Findings Number of criteria in Physical Security: 9 Average percentage of criteria fully met: 89% Range: % Achievements 95% of services have a perimeter fence that conforms to the BS358 standard and is a minimum of three metres in height. All keys held by reception in 95% of low secure services are accounted for at least twice in every 24-hour period. 96% of services have a robust system in place for the reporting and actioning of any identified ligature points or risks. Areas for Improvement 10% of services do not have a clearly delineated external perimeter in which their secure service sits. In as many as 24% of services the external perimeter does not fully maintain the service s integrity, privacy and/ or eliminate climb points or sufficiently manages risk. When reviewed, 26% of services had identified footholds or climb points on gates within their perimeters. Solutions Ensure all staff are clear on where the boundaries to the low secure service are. Review the bolts and locking mechanisms on the gates to remove any potential foot holds. Consider adding a mesh fitting over the windows so that patients still get fresh air but no contraband items can be passed through the gap in the windows. Examples of Good Practice Langdon Hospital: The service uses electronic meet the team and information boards based within the airlocks on each ward. St Mary s Hospital: All staff must undergo a key test and score 100% before being issued with keys. North London Clinic: Each ward has a Health and Safety Champion and a security nurse available on every shift for the management of ligature points and appropriate reporting. St Magnus Hospital: The service uses the Paxton key management system where all fobs are registered to individual members of staff and the fob links to a computer to identify exactly where staff members are within the unit. 36

37 Data Label Figure 11: Percentage of met criteria for Physical Security Average 89% Percentage of Met Criteria 37

38 2: Relational Security Key Findings Number of criteria in Relational Security (inclusive of three criteria for 12 services with patients with learning disabilities, two criteria for services with deaf patients and one female specific standard): Average percentage of criteria fully met: 83% Range: % Achievements 100% of deaf services provide care plans which are accessible and adapted for deaf patients. All learning disabilities services have a combination of nurses trained in mental health and learning disability. 95% of services have clear and effective systems for communication and handover within staff teams. Areas for Improvement Only 38% of services are able to ensure that overnight observations of female patients, in bedroom areas, are undertaken by a female member of staff. 30% of services do not have regular access to an accredited psychotherapist with psychodynamic or psychoanalytic training and forensic experience. 24% of services do not provide patients with access to a range of educational professionals which include teachers, a special education needs co-ordinator, an educational psychologist, or career guidance. Solutions Ensure all patient observations are respectful of patients wishing to get changed or needing momentary privacy. Continue to work with companies such as ASDAN to further develop education sessions which are available to all patients. Consider communicating with female patients the terms of their observations more clearly to avoid conflict over privacy. Examples of Good Practice Allington and Tartentfort Centre: The service has links with the University of Greenwich where patients are employed to be patients for student nurses to gain experience. The patients then rate the student on how well they did. Patients can also work in the canteen on site and do jobs on their ward. Cedar House : The service s education department is a registered ASDAN centre and the service has a teacher and teaching assistant. Rathbone Low Secure Unit: The service pays patients to sit on interview panels and do meet and greet roles. They are also training patients for peer-support worker roles. 38

39 Data Label Figure 12: Percentage of met criteria for Relational Security Percentage of Met Criteria Average 83% 39

40 3: Procedural Security Key Findings Number of criteria in Procedural Security (inclusive of three criteria for 15 services with patients with deaf patients and one female specific standard): Average percentage of criteria fully met: 96% Range: % Achievements All services have policies in place regarding observation, the control and prescribing of medication and drugs and visiting procedures, including child protection issues. 100% of services with female patients have a policy in place regarding restraint and seclusion which addresses the potential requirement for individualised care needs, for example previous trauma or abuse. All deaf services, where there are deaf staff, translate their relevant policies into British Sign Language (BSL) on DVD or communicate live in BSL, as well as being written in plain English. Areas for Improvement 19% of services do not have a policy on the prosecution of offences within the unit which is agreed with the police and CPS. 10% of low secure services do not have an up to date index of procedural security policies in place, including service contingency and business continuity plans. 6% of services did not have a clear complaints procedure in place. Solutions Ensure all policies are submitted to the Quality Network by the self-review deadline. Ensure there is an index of procedural security policies in place at the service. Ensure the service works with the police and CPS to ensure there is an up to date policy on the prosecution of offences. Examples of Good Practice All Saints: Interpreters are provided for deaf staff members to help them understand the policies in place around procedural security. Policies are made as accessible as possible to deaf staff and patients. Gerry Simon Clinic: Patients understand how to make a complaint via the PALS suggestions box which is in the activities area. St Mary s Hospital: The service gives one-to-one time to deaf patients to help them understand policies. Wells Road Centre: Policies regarding restraint and seclusion take into account physical healthcare needs. Seclusion care plans are implemented as soon as a patient enters seclusion, as well as post incident de-briefing in collaboration with advocacy. 40

41 Data Label Figure 13: Percentage of met criteria for Procedural Security Percentage of Met Criteria Average 96% 41

42 C: Service Environment Key Findings Number of criteria in Service Environment: 16 Average percentage of criteria fully met: 78% Range: % Achievements All services have a policy on the use of forced medication, including rapid tranquilisation. 98% of services have an agreed approach to risk assessment including which planning tools are used. 98% of services provide patients with access to outside areas, including secure gardens and court yards, which is determined by an individual risk assessment and takes account of all factors that may assist escape, for example weather. Areas for Improvement 51% of services do not have separate, appropriately furnished facilities for children s visits. 59% of services have identified restricted lines of sight and concealed, unsecured areas on the wards. 37% of services do not have a multi-faith room which is available for use by all patients. 42% of services do not have observation panels with integrated blinds which can be operated by patients from the inside, with additional external override features for staff. Solutions If a room cannot be designated to child visiting, consider placing a box of toys and activities in the visiting room for when children visit. Review ways in which patients are able to control the vistamatic panels in their bedroom doors to ensure that privacy and dignity is maintained. Consider installing parabolic mirrors to help increase lines of sight for frontline staff. Examples of Good Practice Cygnet Hospital Harrow: The service is able to support the financial implications of travel for carers and family members. Alpha Hospital Sheffield: The service has excellent child visiting facilities. There is a baby changing facility next to reception and a hot drinks machine installed in the visiting area. Northgate Hospital: The service has a Getting to Know You scheme that invites visitors to give feedback and create plans with carers about how they would like to be contacted by the service. Ridgeway: There is a separate child visiting room with games and activities appropriate for children of all ages, a TV, seating, a highchair and an outside courtyard. 42

43 Data Label Figure 14: Percentage of met criteria for Service Environment Percentage of Met Criteria Average 78% 43

44 D: Workforce Key Findings Number of criteria in Workforce (inclusive of four criteria for services with 19 patients with learning disabilities and two female specific standards): Average percentage of criteria fully met: 91% Range: % Achievements 100% of Learning Disability services incorporate the aims of Valuing People and Valuing People Now and Person-Centred Planning. All Learning Disability services who have staff working with people with learning disabilities are trained to do so. 98% of all services use training which addresses the management of violence and aggression, which also includes de-escalation techniques and the use of control and restraint procedures. Areas for Improvement 36% of services do not provide all staff with supervision on a monthly basis. 28% of services do not have a staffing capacity that is sufficient to deliver the care and treatment model and maintain a safe environment at all times. Only 21% of services provide their staff with a service specific programme of training. Solutions Consider developing a supervision passport for staff to record and manage their own supervision, ensuring at least one hour of supervision is received each month. Ensure all staff undertake supervision on a monthly basis and ensure it is monitored and audited regularly. Consider the need for gender specific training which staff might find useful. Examples of Good Practice Alpha Hospital Bury: Supervision passports are carried by all members of staff and focus groups take place as added support for staff. Maplewood: The service receives monthly visits from Women in Secure Hospitals (WISH) and they deliver training around issues affecting the female patient group. Cygnet Hospital Derby: Staff receive both management and clinical supervision and time is protected for all staff. The Clee Unit: Reflective practice also takes place at the service and staff have engaged in the 'Healing Environment' supervision programme, which is followed by 6 supervision sessions. 44

45 Data Label Figure 15: Percentage of met criteria for Workforce Percentage of Met Criteria Average 91% 45

46 E: Governance Key Findings Number of criteria in Governance: 5 Average percentage of criteria fully met: 81% Range: % Achievements 100% of all services have a structure in place for reporting, managing and investigating Serious and Untoward Incidents (SUIs). 99% of services have mechanisms in place to share learning beyond the immediate service or provider concerning incidents. Areas for Improvement 47% of services do not have contingency plans in place which are tested by a live exercise involving one or other of the emergency services every 24 months. 44% of services do not have contingency plans in place which are annually tested by desktop exercises. 11% of services do not have a contingency plan in place, which has been agreed with the police, regarding the reporting and managing of incidents. Solutions Liaise with the local police emergency planning department to develop an agreed contingency plan to cover all eventualities. Consider looking at the LSU discussion group to gain ideas about how to introduce desktop exercises in order to test contingency plans. Consider designing a service-specific programme of desktop and live exercises that can be carried out to test service contingency plans. Examples of Good Practice All Saints: The service holds meetings with other Trusts who offer specialist deaf services to discuss issues around incidents and lessons learned and sharing of this information. Bracton Centre: A quarterly newsletter highlighting SUI s and lessons learned is produced and disseminated to all ward staff. St Mary s Hospital: The service has employed a dedicated Family and Friends Representative who attends Clinical Governance meetings to help review and develop the service. Tony Hillis Wing: Desktop and live exercises are run regularly including a full scale evacuation of the unit. The fire brigade are involved in the additional emergency planning forums. 46

47 Data Label Figure 16: Percentage of met criteria for Governance Percentage of Met Criteria Average 81% 47

48 F: Equalities Key Findings Number of criteria in Equalities (inclusive of two criteria for services with 20 patients with learning disabilities, four criteria for services with deaf patients and three female specific standards): Average percentage of criteria fully met: 87% Range: % Achievements 99% of services have access to a range of appropriate advocacy services for their patients to use for support and independent representation. 96% of services take on the views of patients, their carer s and others when discussing the redesigning, planning, delivering and importantly the improvement of health care services. 95% of services include one female member of staff in the pre-assessments of female patients. Areas for Improvement 21% of services do not sufficiently use feedback from patients, friends and family to make improvements to the quality of the units. Only 66% of services are providing patients with satisfactorily balanced and healthy meals, with appropriate portion sizes, catering for dietary requirements. 26% of services did not offer families counselling or support sessions throughout Cycle 3. There may have been variations to the support offered. Solutions Consider ward based you said, we did boards highlighting requests from feedback made and updateable information about actions and timeframes. Review ways in which the service can signpost and help family and friends access psychological support through their own General Practitioner. Continue to promote self-catering opportunities to patients and consider increasing the frequency of this. Examples of Good Practice Hollins Park Hospital: Patients are involved in interviewing new members of staff. Cygnet Hospital Blackheath: Patients are involved in collaborative risk assessment training, service decoration, how wards are run and what groups are made available to them. Morris Ward: The service offers psycho-educational sessions to families and carers of patients. Rathbone Low Secure Unit: Patients are able to communicate with the Chief Executive of the Trust via the Tell Joe process. 48

49 Data Label Figure 17: Percentage of met criteria for Equalities Average 87% Percentage of Met Criteria 49

50 Standard Met Partly Met Unmet N/A APPENDIX A: AGGREGATED DATA (Total number of units meeting each standard) Model of Care Standard A1 Admission A1.7 All patients will have an initial plan in place within 24 hours of admission A1.8 All patients have a link person/care co-ordinator from their home area services whose responsibilities include the facilitation of ongoing links and the patient s care pathway A1.9 There are clear criteria for admission to and transfer /discharge from services which will be agreed with commissioners and will be communicated to all referrers. The service ensures that the discharge procedures are operated in line with the pathway (appendix 4) A2 Recovery Using the Care Programme Approach (CPA), the multi-disciplinary team takes a A2.1 comprehensive, recovery-focussed approach aimed at building resilience and preventing relapse. A2.2 The recovery-focussed approach includes addressing accommodation, employment and learning needs, meaningful social contact and combating stigma A2.6 There is provision for patients requiring a period of engagement and treatment away from the main patient group. This may include the provision of h for de-escalation and seclusion. A2.7 There are a variety of recreational activities and occupational facilities available A2.9 There are effective links with community organisations (e.g. housing, leisure, employment, education) and activities to support rehabilitation and sustainable discharge A2.10 There is evidence that the service places the patient at the centre of their care, supporting patient recovery and choice within the unit where this is clinically appropriate A2.12 Patients are given a copy of the management or care plan or have ready access to it A2.16 The programme of treatment includes psychological sessions A2.17 The programme of treatment includes substance misuse therapy A2.18 The programme of treatment includes offence related therapy A2.19 The programme of treatment includes structured activity programmes Met Partly Met Unmet N/A 50

51 Standard Met Partly Met Unmet N/A A2.22 There are facilities appropriate to the patient group, e.g. a pool table and board/console games are provided A2.23 There are facilities for patients to make their own hot and cold drinks and snacks A2.24 Books and magazines are provided in recreation areas for patients CPA1 Patients are included in all parts of their CPA Meeting except in exceptional circumstances. When a patient cannot be involved, they will be informed of this CPA3 Patients discuss, negotiate and agree with their care coordinator on who should be invited to their CPA meeting, and a joint decision made on what happens if people are unable to attend. CPA7 At least one week before the meeting, patients are involved in the writing of all CPA reports, including future/discharge planning CPA15 Patients will be shown a copy of the final draft report after the CPA meeting and will have the opportunity to add their views at this stage A3 Physical Healthcare A3.1 Patients routinely undergo a full assessment of both physical and mental health needs A3.3 Patients have access to a comprehensive range of primary healthcare services A3.6 Patients are supported in their personal care including dental hygiene A3.8 The service provides general health promotion activities including screening, diet advice and the opportunity to exercise (with appropriate supervision) A3.11 Patients have access to comprehensive primary and secondary care services to meet existing or newly developed physical healthcare and treatment needs Deaf. Access to health services (e.g. Dentist, GP) is supported by appropriate staff to aid 29 communication G1w All women have access to a female General Practitioner and practice nurse G4w All women have access to primary and secondary screening programmes, e.g. cervical screening, mammography A4 Discharge Social workers, care coordinators and offender managers are actively involved in care A4.1 planning processes for treatment on the unit and post-discharge follow-up under Section arrangements. A4.3 There is a multi-disciplinary assessment to determine readiness for discharge/transfer A4.4 The multi-disciplinary team supports the patient to develop and maintain links with community-based organizations that can provide socially inclusive, mainstream activities

52 Standard Met Partly Met Unmet N/A B Safe Therapeutic Environment B1 Physical Security B1.1 There is a clearly delineated external perimeter B1.2 The external perimeter is designed to maintain service integrity, privacy, eliminate climb points and manage risk. (The exact nature of the external perimeter, for example fence height, cladding, angled weld mesh topping, and anti-climb capping, is determined by the size, layout and location of the low secure service). B1.3 Gates within the perimeter do not have bolts or opening mechanisms that can be used as footholds to assist climbing B1.4 Where fencing forms all or part of the secure external perimeter, it is recommended this conforms to BS358 and is a minimum height of 3 metres B1.5 Access to the low secure unit for visitors, staff and patients is via an air lock B1.7 There is a clearly defined internal perimeter (normally bounded by the secure doors leading to outside areas) which facilitates patients freedom of movement within the internal perimeter area. B1.10 All keys, including those held at reception, are controlled, issued and accounted for B1.11 All keys held by reception are accounted for at least twice in a 24-hour period B1.20 There is a system in place for staff to report any ligature points identified with prompt follow up action B2 Relational Security B2.4 There are clear and effective systems for communication and handover within staff teams B2.6 There are regular meetings where staff discuss and reflect on relational security issues. This includes as a minimum discussion of boundaries, therapy, patient mix, patient dynamic, patient s personal world, physical environment, visitors and other external communication and may be facilitated by the See, Think, Act Relational Security Explorer B2.9 There is annually updated staff training on relational security. This includes as a minimum material on: boundaries, therapy, patient mix, patient dynamic, patient s personal world, physical environment, visitors and other external communication This may be facilitated by the See, Think, Act training slides B2.13 The unit has access to a range of education professionals which include teachers, a special educational needs co-ordinator, an educational psychologist, and career guidance B2.14 The programme of treatment includes access to real opportunities to work Deaf. Care plans are accessible to deaf patients and if necessary adapted for deaf patients e.g. 3.8 using pictures, symbols or in BSL on DVD or other formats

53 Standard Met Partly Met Unmet N/A Deaf. 3.9 The multidisciplinary team includes clinicians with expertise in mental health and deafness LD. 2.1 Senior Clinicians are trained in Learning Disability and Forensic Psychiatry LD. 2.2 There is a combination of nurses trained in mental health/learning disability LD. 2.3 There is access to a Speech and Language Therapist with experience in learning disabilities and mental health A9w All overnight observations in bedroom areas are undertaken by female staff Psychotherapy. The service has regular access to an accredited psychotherapist with a psychodynamic or psychoanalytic training and forensic experience B3 Procedural Security B3.1 There is an up to date index of procedural security policies used in the low secure service, including contingency and business continuity plans B3.8 Staff, patients and visitors are clear about rules and policies governing any prohibited items including cameras and electronic devices and other items that may be restricted such as mobile phones. B3.9 There are policies governing access to and appropriate use of the internet by staff and patients B3.11 There is a readily available policy for the authorisation of and governance of practice of, searching patients, patient rooms, communal areas and visitors. This policy is in accordance with the requirements of the Mental Health Act Code of Practice. B3.12 There is a policy on observation B3.13 There is an anti-bullying policy (for those who are bullying and those who are bullied) B3.16 There is a policy on the control of prescribed medication and drugs B3.20 There is a policy on the prosecution of offences within the unit which is agreed with the police and CPS B3.25 There is a policy on visiting procedures including child protection issues B3.33 There is a clear complaints procedure B3.34 There is a procedure regarding obtaining consent from patients Deaf. 2.1 All relevant policies and procedures are impact assessed in terms of deafness Deaf. Where there are deaf staff, relevant policies are translated into BSL on DVD or 2.2 communicated live in BSL (or another signed language) and written in plain English Deaf There is a statement of how prohibited items may differ where there are deaf patients (e.g. mobile phones, webcams, Skype, s to facilitate communication)

54 Standard Met Partly Met Unmet N/A A2w Policies regarding restraint and seclusion address the potential requirement for individualised care needs e.g. Previous trauma or abuse, physical health issues, advanced directives C Service Environment C1.2 The patient and staff environment is homely, light and bright C1.5 There is a multi-faith room available for use by all patients C1.6 There are unrestricted lines of sight and no concealed unsecured areas C1.7 Furnishings minimise the potential for fixtures and fittings being used as weapons, barriers or ligature points C1.8 Doors in rooms used by patients have observation panels with integrated louvre blinds. These can be operated by patients with an external override feature for staff C1.10 Patient bedroom doors and bathrooms open 2-ways to prevent holding, barring or blocking C1.11 There are lockable facilities (with staff override feature) for patient s personal possessions with maintained records of access C1.12 Patients have access to a telephone in a private area, within the limits of safety and risk assessment C2.5 There is an agreed approach to risk assessment including which planning tools are used C3.1 There are clear policies and procedures governing the use of de-escalation techniques and the management of challenging behaviour including the appropriate use of control and restraint and of seclusion. C3.2 There is evidence that the service has considered how best to provide appropriate deescalation facilities and considered the need for providing an en-suite seclusion room that will maintain the patient s safety, privacy and dignity. C3.4 Where required rapid tranquilisation complies with NICE guidance ( C4.1 Access for patients to outside areas including secure gardens and court yards is determined by an individual risk assessment and takes account of all factors that may assist escape, e.g. weather. C5.1 There are facilities for visitors within the secure perimeter C5.2 There are separate, appropriately furnished facilities for children s visits C5.6 The unit works with visitors and families on their health and well being, for example, coping with stress, conflict resolution and sustainable transport plans for visiting

55 Standard Met Partly Met Unmet N/A D Workforce D1.1 There is a cohesive multi-disciplinary team in place who have the capacity and capability required to meet the complex needs of patients D1.3 The staffing capacity is sufficient to deliver the care and treatment model and maintain a safe environment at all times D1.5 Extra nursing cover is available when needed, e.g. there is access to additional on-call staff in emergency LD. 2.5 There is a local protocol in place so there is access to an epilepsy specialist (who may be the Responsible Clinician) LD. 3 The service incorporates the aims of Valuing People and Valuing People Now and person centred planning e.g. with Health Action Plans A16w There are sufficient staff available to enable children to visit during evenings and weekends D2.3 The staff at the service have completed the mandatory and appropriate non-mandatory training provided by the organisation D2.6 There is an annually reviewed training and development strategy which includes the provision of security training D2.8 All staff receive supervision on a monthly basis D2.9 All staff receive training regarding Safeguarding Children and Safeguarding Vulnerable Adults D2.11 Staff receive training on Physical Security as part of the induction programme and prior to being issued with keys, swipe cards or other means of operating Physical Security mechanisms. D2.12 Staff receive training on Procedural Security as part of the induction programme and prior to being issued with keys, swipe cards or other means of operating Physical Security mechanisms. D2.13 Staff receive training on Relational Security as part of the induction programme and prior to being issued with keys, swipe cards or other means of operating Physical Security mechanisms. D2.14 All staff including non-clinical staff receive training in the management of violence and aggression D2.15 Training addressing the management of violence and aggression includes de-escalation techniques and the use of control and restrain procedures D2.21 Staff take up of supervision and support is regularly monitored and audited LD. 1 Staff working with people with learning disabilities are trained to work with people with learning disabilities

56 Standard Met Partly Met Unmet N/A Managers ensure that all staff receive training in working with people with learning LD. 1.2 disabilities, autism spectrum conditions and epilepsy The service-specific programme of training will include: - gender responsive practice - inclusive practice and issues of discrimination - culturally responsive practice - victim issues (including domestic and sexual violence, other trauma and supporting C4w disclosure) - gender influenced presentation of mental Illness - personality disorder - eating disorders - deliberate self-harm - child protection and liaison with Children s Services E Governance E1.1 E1.7 There is a structure in place for reporting, managing and investigating Serious and Untoward Incidents (SUIs). There are mechanisms in place to share learning beyond the immediate service/provider concerning incidents E2.1 The unit has a contingency plan in place, which has been agreed with the police, regarding the reporting and managing of: loss of control serious operational failures including those resulting from fire (in agreement with the local fire and emergency services) escapes absconds failure to return and hostage taking. E2.8 Contingency plans are annually tested by desktop exercises E2.9 Contingency plans are tested by a live exercise involving one or other of the emergency services every 24 months

57 Standard Met Partly Met Unmet N/A F Equalities F4 Service users are provided with a range of information, in appropriate formats, regarding their rights under equalities, mental health and human rights legislation F5 Service users have access to a range of appropriate advocacy services F8 There is an implemented policy setting out the consultation and involvement of carers in the care provided F10 The views of patients, their carers and others are sought and taken into account in designing, planning, delivering and improving health care services F11 Feedback from patients and carers is used to improve the quality of the unit F14 Complaints are continually monitored to identify trends and learning points which are reviewed quarterly F17 Staff demonstrate respect for patients F18 Patients are encouraged to personalise their bedroom spaces appropriately. (Pictures of nude bodies or pictures of children may be inappropriate) F19 Patients are provided with meals which are of a high quality, 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 (Better Hospital Food Department of Health 2004). Deaf. 6 The complaints procedure is accessible to deaf people Deaf. There is information available for contacting advocacy which is suitable for deaf patients 11 e.g. minicom/fax numbers Deaf. 13 The service has access to spiritual leaders able to communicate with deaf people Deaf. Patients rights and what they are to expect are explained in a manner accessible to deaf 15 people LD. 4 There is access to clear and easy to understand information in accessible formats (e.g. leaflets and other media) LD. 4.3 Patients are given assistance by staff to help them to understand the information E2w The pre-admission assessment team ideally includes at least one female member of staff E9w The service offers gender specific access to all therapeutic and recreational activities E10w The service offers mixed-gender access to appropriate therapeutic and recreational activities Carer. 1 The unit provides links to local Carer Advocacy services Carer. 2 The unit offers counselling/support sessions to the families of service users

58 Unit Name Trust/Organisation No. of Completed LSU Cycles No. of low secure wards reviewed in Cycle 3 APPENDIX B: MEMBER UNITS Bowlers Green 58 Unit Name Trust/Organisation Hertfordshire Partnership NHS Foundation Trust No. of Completed LSU Cycles No. of low secure wards reviewed in Cycle All Saints Hospital St George's Healthcare Group 3 1 Allington & Tarentfort Centre Kent and Medway NHS and Social Care Partnership Trust 2 1 Alpha Hospital Bury Alpha Hospitals 3 9 Alpha Hospitals Sheffield Alpha Hospitals 3 1 Alpha Hospitals Woking Alpha Hospitals 3 2 Amber Lodge Rotherham, Doncaster and South Humber NHS Foundation Trust 2 1 Ansel Clinic Ansel Group 3 2 Arbury Court Partnerships In Care 3 6 Ash Ward Somerset Partnership NHS Foundation Trust 3 1 Bade Ward Northumberland Tyne and Wear NHS Foundation Trust 3 4 Beech House Hospital The Huntercombe Group 1 4 Beech Ward Hertfordshire Partnership NHS Foundation Trust 3 1 Bowman Centre Cornwall Foundation Trust 2 1 Bowness Unit Greater Manchester West Mental Health NHS Foundation Trust 3 16 Bracton Centre Oxleas NHS Foundation Trust 3 8

59 Unit Name Trust/Organisation No. of Completed LSU Cycles No. of low secure wards reviewed in Cycle 3 Bradley Woodlands Light House Healthcare 2 2 Brockfield House South Essex Partnership NHS Foundation Trust 3 9 Brooklands Hospital Coventry and Warwickshire Partnership Trust 1 4 Burston House Partnerships In Care 3 3 Cedar House The Huntercombe Group 1 3 Cheswold Park Hospital Cheswold Park Hospital 3 8 Chichester Centre Sussex Partnership NHS Foundation Trust 3 3 Clare Ward Belfast Health and Social Care Trust 3 4 Clifton House 59 Leeds and York Partnership NHS Foundation Trust 2 4 Cygnet Hospital Beckton Cygnet Health Care 1 1 Cygnet Hospital Bierley Cygnet Health Care 1 2 Cygnet Hospital Blackheath Cygnet Health Care 2 1 Cygnet Hospital Derby Cygnet Health Care 3 2 Cygnet Hospital Godden Green Cygnet Health Care 2 1 Cygnet Hospital Harrow Cygnet Health Care 2 1 Cygnet Hospital Kewstoke Cygnet Health Care 3 1 Cygnet Hospital Stevenage Cygnet Health Care 2 4 Eaglesone View Priory Group 3 8 Edward House Ellesmere House North Essex Partnership University Foundation NHS Trust South Staffordshire & Shropshire Healthcare NHS Foundation Trust Farmfield Hospital Priory Group 3 5 Forest Lodge Sheffield Health and Social Care NHS FT 3 1

60 Unit Name Trust/Organisation No. of Completed LSU Cycles No. of low secure wards reviewed in Cycle 3 Foxhall House Norfolk & Suffolk Foundation Trust 3 1 Francis Willis Unit Lincolnshire Partnership NHS Foundation Trust 2 1 George Mackenzie House 60 Cambridge & Peterborough Mental Health Foundation Trust 1 1 Gerry Simon Clinic Black Country Partnership Foundation Trust 3 1 Guild Lodge Lancashire Care NHS Foundation Trust 3 11 Hazelwood House Partnerships In Care 3 1 Hellesdon Norfolk & Suffolk Foundation Trust 3 2 Hillis Lodge Birmingham and Solihull Mental Health Foundation Trust 3 8 Hollins Park Hospital 5 Boroughs Partnership NHS Foundation Trust 3 3 Humber Centre Humber NHS Foundation Trust 2 7 Kemple View Partnerships In Care 3 4 Kneesworth House Hospital Partnerships In Care 3 5 Langdon Hospital Devon Partnership Trust 3 6 Lee Mill Unit Plymouth Community Healthcare 1 1 Llanarth Court Hospital Partnerships In Care 3 7 Maplewood Calderstones Partnership NHS Foundation Trust 2 3 Meadow View Caring Homes / Curate 3 2 Morris Ward North East London NHS Foundation Trust 1 1 Newhaven & Bretton Centre Newsam Centre South West Yorkshire Partnership NHS Foundation Trust Leeds and York Partnership NHS Foundation Trust North London Clinic Partnerships In Care 3 3

61 Unit Name Trust/Organisation No. of Completed LSU Cycles No. of low secure wards reviewed in Cycle 3 North London Forensic Service Northgate Hospital 61 Barnet, Enfield and Haringey Mental Health Trust Northumberland Tyne and Wear NHS Foundation Trust Oaktree Manor Partnerships In Care 3 3 Oxford Clinic Oxford Health NHS Foundation Trust 3 5 Rathbone Low Secure Unit Mersey Care NHS Trust 3 2 Ridgeway River house Tees, Esk and Wear Valley NHS Foundation Trust South London and Maudsley NHS Foundation Trust Robin Pinto Unit South Essex Partnership NHS Foundation Trust 1 1 Saddlebridge Recovery Centre & Alderley Unit Shaftesbury Clinic Cheshire and Wirral Partnership NHS Foundation Trust South West London & St George's Mental Health NHS Trust Southfield Low Secure Unit Southern Health NHS Foundation Trust 3 3 Southview Sussex Partnership NHS Foundation Trust 3 1 St Andrew's Healthcare Birmingham St Andrew s Healthcare 3 8 St Andrew's Healthcare Essex St Andrew s Healthcare 3 4 St Andrew's Healthcare Northampton - CAMHS Service St Andrew's Healthcare Northampton - Womens Service St Andrew's Healthcare Northampton- Men's Service St Andrew's Healthcare Nottinghamshire St Andrew s Healthcare 1 8 St Andrew s Healthcare 1 8 St Andrew s Healthcare 1 10 St Andrew s Healthcare 3 4 St John's House LDS Partnerships In Care 3 4

62 Unit Name Trust/Organisation No. of Completed LSU Cycles No. of low secure wards reviewed in Cycle 3 St Magnus Hospital St Magnus 3 3 St Mary's Hospital St George's Healthcare Group 2 2 Sutton's Manor Partnerships In Care 3 2 The Clee Unit South Staffordshire & Shropshire Healthcare NHS Foundation Trust 1 2 The Dene Partnerships In Care 3 3 The Orchard West London Mental Health Trust 1 4 The Spinney Partnerships In Care 3 5 Thornford Park Hospital Priory Group 3 8 Tony Hillis Wing West London Mental Health Trust 2 7 Wells Road Nottinghamshire Healthcare NHS Trust 2 5 West Drive Calderstones Partnership NHS Foundation Trust 2 5 Wickham Unit Avon and Wiltshire Partnership Trust 3 11 Wolfston House East London NHS Foundation Trust 3 15 Wood House Light House Healthcare 1 1 Wood Lea Clinic South Essex Partnership NHS Foundation Trust 1 1 Woodlands House Oxford Health NHS Foundation Trust

63 Service Name Achievement Contact Name Contact Number Contact APPENDIX C: EXAMPLES OF GOOD PRACTICE Model of Care Admission Service Name Achievement Contact Name Contact Number Contact Amber Lodge Ansel Clinic Chichester Centre Clifton House Cygnet Hospital Beckton Cygnet Hospital Bierley Cygnet Hospital Derby Hazelwood House Wolfston House All potential admissions and discharges are discussed at the weekly referrals meeting which is chaired by the Clinical Director. Patients are admitted with an Advance Statement where they are able to specify how they wish to be treated in certain circumstances. Draft core care plans are completed prior to admission and revised upon admission dependent upon the presenting risk. All patients will have a designated care coordinator who will maintain contact with the patient throughout their stay. Care coordinators are invited to attend ward rounds and CPA meetings. Dates are flexible and videoconferencing can be used to encourage input from external care teams/link persons. Staff visit patients prior to admission and give them an information booklet as well as an additional booklet when they are admitted. Patients have a buddy system which helps to support new patients with their initial introduction to the service. Care plans are based on Needs Formulations and the overarching model used is My Shared Pathway. Ex-patients return to the service to co-facilitate groups and disclose their personal testimonies to the patient group. Louisa Endersby Assistant Director Forensic Services Richard Idle Registered Manager Nick Badoorally Matron Mark Dodd Matron & Mike Waldie Ward Manager Judith Etheridge Hospital Manager Jenny McVinnie Hospital Manager Mark Varney Hospital Manager Palmer Chinosengwa Registered Manager Deborah Bull Deputy Head of Service Louisa.endersby@rdas h.nhs.uk Richard.Idle@cambiang roup.com Nick.badoorally@susse xpartnership.nhs.uk Mark.dodd2@nhs.net Mike.waldie@nhs.net judithetheridge@cygne thealth.co.uk jennymcvinnie@cygnet health.co.uk markvarney@cygnethe alth.co.uk Palmer.chinosengwa@p artnershipsincare.co.uk Debbie.Bull@eastlondo n.nhs.uk 63

64 Service Name Achievement Contact Name Contact Number Contact Lee Mill Unit North London Clinic Robin Pinto Unit Clare Ward St Andrew's Healthcare Nottinghamshire St John s House LDS Bade Ward Tony Hillis Wing The service uses a buddy system for new admissions. A patient who has been at the service for a while will make a phone call to the new admission and then visit the current hospital they are being transferred from. This ensures patients have a friendly face when they arrive on the ward. All patients have an allocated care coordinator from their locality, in addition to a placements officer/commissioner. All of whom are kept up to date regularly on a patient s progress and are invited to attend CPA meetings and other meetings. Patients who have been in the service for a period of time are under the care coordination of the inpatient social worker and this will continue for 6 months post discharge. Patients from Belfast Trust have an existing care plan which is transferred with them and then amended by the nursing team upon admission. All patients have social workers in the community. All patients have a care plan in place on admission covering their first few days in the service during which time the multi-disciplinary team complete an admissions check list and care plan formulation. There is a pre-admissions meeting to develop preliminary care plans as well as a transitional period for new admissions. Community practice nurses and social workers from the patient s home area are invited to CPA meetings and ward rounds in order to maintain ongoing links in patients pathways. Jane Quigley Ward Manager Gary Stobbs Unit Manager Shona Little Integrated Clinical Lead Noel McDonald Operations Manager Lisa Powell Hospital Director Fungai Nhiwatiwa Unit Manager janequigley@nhs.net Shirley Wakefield Service Manager Dawn Harwood Head of Service Gary.stobbs@partnersh ipsincare.co.uk shona.little@sept.nhs.u k noel.mcdonald@belfast trust.hscni.net lpowell1@standrew.co. uk fungai.nhiwatiwa@part nershipsincare.co.uk Shirley.wakefield@ntw. nhs.uk Anouschka.Marwick@nt w.nhs.uk Dawn.harwood@wlmht. nhs.uk 64

65 Service Name Achievement Contact Name Contact Number Contact Wells Road Centre Wood Lea Clinic Commissioners are involved in Bed Management Meetings and Through Care Meetings, as well as input from Community Teams for appropriate and long standing discharge placements. Gate keeping assessments are conducted to identify suitability for admission and the assessment results are presented to the commissioners to allocate beds. Lorraine Lockley Modern Matron Shona Little Integrated Clinical Lead c.nhs.uk k Recovery Team Name Achievement Contact Name Contact Number Contact All Saints Alpha Hospital Sheffield Alpha Hospital Woking Arbury Court Ash Ward Bowman Centre The service is part way through developing a recovery package similar to My Shared Pathway that is specific to the deaf service and written in British Sign Language. The service has a controlled hot water dispenser which is set to 80 degrees. Patients can access this at any time of the day to make hot and cold drinks. There are a range of recreational activities available, including gym, yoga, table football, computing, cooking and community visits. The service offers a variety of recreational activities and occupational facilities including a pamper suite, pets as therapy and horticulture. Patients have daily meetings on the ward as well as have your say meetings and a suggestions box where they can request changes to be made to the service. Staff at the service remain in contact with all patient for one month after they have been discharged. Bernadette McCafferty Registered Manager Julie Donovan Hospital Director Sam Antwi-Marful Hospital Director Sue Taylor Lead Nurse Colin Reynolds Ward Manager William Fearnley Acting Ward Manager MarieMcCafferty@stgeo rgehealthcaregroup.co. uk Cc in SamanthaTattersall@st georgehealthcaregroup. co.uk Julie.Donovan@alphaho spitals.co.uk Sam.Antwi- Marful@alphahospitals. co.uk Sue.taylor@partnership sincare.co.uk colin.reynolds@sompar.nhs.uk william.fearnley@nhs.n et 65

66 Service Name Achievement Contact Name Contact Number Contact Bradley Woodlands Brooklands Hospital West Drive Cheswold Park Hospital Chichester Centre Cygnet Hospital Harrow Cygnet Hospital Kewstoke Bowness Unit Edward House Francis Willis Patients are involved in quality monitoring systems at the service, including presenting on behalf of the service. There are a wide variety of offence related treatment programmes primarily using the CBT model e.g. fire setting groups and Sexual Offending Treatment Program (SOTP). There are a variety of recreational activities on offer to the patient group, including: a pool club, ramble group, creative arts, gym, upholstery, circuits, learning to fish, news and views and samba drumming. The service have formed a band including patients and staff that practice on a regular basis and perform within the hospital. There is a large pool of psychological resources and treatment programs offered including violence management, substance misuse and offence related work. There are a wide range of therapies and sessions offered to patients, including: index offence related therapy; diagnosis confirmation; problem solving; anger management and group treatment sessions. There is a dedicated drug and alcohol therapist at the service and narcotics and alcoholics anonymous groups both on site and in the community. There is a bike maintenance project where patients can help with building bikes to allow them to be sold. Ex-patients are also involved in this volunteering. New admissions to the service have a CPA within the first two months of arriving at the service. The service has two experienced drug and alcohol nurses who facilitate sessions on substance misuse. Kath Dye Hospital Manager Lesley Wilson Matron Lynne Kirwan Operational Support Manager David Williams Director of Nursing Nick Badoorally Matron Seamus Quigley Hospital Manager David Colyer Hospital Manager Rachel Green Deputy Head of Operations Fiona Thomas Operational Services Manager Jocelyne White Ward Manager Kath.dye@lighthousehealthcare.co.uk Lesley.wilson@covwark pt.nhs.uk lynne.kirwan@calderso nes.nhs.uk dwilliams@cheswoldpar khospital.co.uk Nick.badoorally@susse xpartnership.nhs.uk seamusquigley@cygnet health.co.uk davidcolyer@cygnethea lth.co.uk rachel.green@gmw.nhs.uk Fiona.thomas@nepft.nh s.uk jocelyne.white@lpft.nhs.uk 66

67 Service Name Achievement Contact Name Contact Number Contact Wickham Unit George MacKenzie House Gerry Simon Clinic Guild Lodge Hollins Park Hospital Wolfston House Kemple View Kneesworth House Hospital Meadow View Newton Lodge North London Forensic Service There is a "getting out, staying out" group for patients, which deals with social isolation and stigma. There is a visiting mobile library which comes to the service every three weeks. Tutors from Walsall College come in every Monday to provide education sessions for patients. Patients are invited to be involved in the training and recruiting of staff, including Control and Restraint talks and care planning development. There was a relaxing low stimulus room for patients with a Mural on the wall. Training is provided to the local hostels to educate them on issues around mental health and how to respond in certain situations, providing the service with strong links with local accommodation services. The CPA process focuses on recovery aspects such as relapse prevention, early warning signs, support networks and self-harm reductions. There is a selection of recovery tools held on the wards for patients to choose from. This enables patients to choose an approach that best suits them and their recovery. There is a local bank system in place to help patients set up a bank account and benefits which was commended by the peer-review team. Patients on Newhaven have a CPA meeting every 3 months. The service reported using recovery star and having established a psycho-educational programme called recovery and enablement designed to support patients in recovery and enable skill development to move forward. Julie Somerville Lead Occupational Therapist Wendy Scott-Earl Service Manager, Specialist Services Dr Joseph Vella Consultant Psychiatrist Lee Drake Integrated Clinical Manager Sue Lee Modern Matron - Secure Services Deborah Bull Deputy Head of Service Mark Haslam Clinical Nurse Manager Linda Ram Head of Social Work & Patient Related Services Stuart Docherty Business Performance Manager Catherine Eaves Interim General Manager Low Secure Services Sara Henley Head of Therapies julie.somerville@nhs.ne t joe.vella@bcpft.nhs.uk Lee.drake@lancashirec are.nhs.uk Sue.lee@5bp.nhs.uk Debbie.Bull@eastlondo n.nhs.uk Mark.Haslam@partners hipsincare.co.uk Linda.ram@partnership sincare.co.uk sdocherty@caringhome s.org Catherine.eaves@swyt. nhs.uk Wendy.scottearl@cpft.nhs.uk Sara.henley@behmht.nhs.uk 67

68 Service Name Achievement Contact Name Contact Number Contact Oaktree Manor Rathbone Low Secure Unit Hillis Lodge River House Saddlebridge Recovery Centre & Alderley Unit Southfield Low Secure Unit Southview St Andrew's Healthcare Birmingham St Andrew's Healthcare Northampton - CAMHS Service St Andrew's Healthcare Northampton - CAMHS Service The service offers a variety of recreational activities, including: independent living skills, art and craft, budgeting, current affairs group, music and self-esteem. There is evidence of patient involvement in all aspects of the service, for instance the unit is hosting a paint party to allow patients to be involved in the redecoration of their bedrooms. There are links to the BETA employment project. Each ward has a My Shared Pathways Forum and patients have had training in My Shared Pathways and some are now MSP Champions. The seclusion room has a lounge area and individual courtyard so patients can access fresh air. The walls in the lounge area have been designed as a beach scene. Patients reported receiving a copy of their care plans and are able to write their care plan if they want to. Patients are involved in all aspects of their CPA meetings from preparation pre meeting to discussions about the reports post meeting. Patients commented positively on patient involvement at the service. Including recruitment panels and the food forum. The education provision for St Andrew s Healthcare CAMHS achieved outstanding in their most recent Ofsted inspection. The TERF centre hosts educational trips, e.g. a poppy picnic for the WW1 centenary, a trip to the Warner Bros. Harry Potter Studios and a trip to Thorpe Park. Beatrice Nyamande Registered Manager Sara Finlayson Head of Psychological Services Jan Morris Service Development Manager Ellie Bateman Service Director Dave Jones Clinical Service Manager Dr Luke Birmingham Consultant Forensic Psychiatrist Nick Clark General Manager Victoria Hitch Lead Occupational Therapist David Rodgers Ward Manager David Rodgers Ward Manager Beatrice.nyamande@pa rtnershipsincare.co.uk sara.finlayson@mersey care.nhs.uk Jan.morris@bsmhft.nhs.uk Eleanor.Bateman@slam.nhs.uk david.jones@cwp.nhs.u k luke.birmingham@sout hernhealth.nhs.uk Nick.Clark@sussexpart nership.nhs.uk vhitch@standrew.co.uk drodgers@standrew.co. uk drodgers@standrew.co. uk 68

69 Service Name Achievement Contact Name Contact Number Contact St Andrew's Healthcare Northampton- Men's Service St Magnus Hospital St Mary s Hospital The Clee Unit The service has 3 levels of a substance misuse programme, from the educational level to relapse prevention. Community trips have included visits to Birdworld, National Trust sites, the coast and sport matches. The service has a minibus to take groups of patients on visits and also a disability vehicle. St Mary s Hospital run a Permitted Earnings Scheme to provide patients with opportunities to develop their skills and access voluntary work placements within the community. Patients have 25 hours of activities a week and there was much evidence of a stimulus environment around the wards, including access to board games, a well-equipped art room and gym and occupational support. Lynn Baxter Hospital Director Dr Patrick O Sullivan Medical Director Christine Walker Deputy Hospital Manager Samantha Mason Low Secure Pathway Lead lbaxter@standrew.co.u k drosullivan@stmagnus. co.uk christinewalker@stgeor gehealthcaregroup.co.u k samantha.mason@sssft.nhs.uk The Dene There are patient representatives as part of the clinical governance and patient council meetings. Alexandra Thurlby, Hospital Director Alexandra.thurlby@part nershipsincare.co.uk The Orchard Tony Hillis Wing Wood House Woodlands House The service ensures patients are involved in all aspects of their CPA meetings and allows them to complete self-reports which are incorporated into CPAs and ward rounds. There are Service User Consultants for each ward to represent patient s opinions and to support other patient s recovery processes. Patients are given swipe cards to allow them access to the kitchen which they are risk assessed for. All patients currently on the ward had their own swipe cards. The service has access to a dual-diagnosis nurse who visits the unit once a week. This resource is used to identify issues with substance misuse and patients can be referred to a programme with tiered progression. Doreen Whande Senior Nurse Dawn Harwood Head of Service Simon Reed Hospital Manager Preeteema Gungah Ward Manager doreen.whande@wlmht.nhs.uk Dawn.harwood@wlmht. nhs.uk Simon.reed@lighthouse -healthcare.co.uk Preeteema.gungah@oxf ordhealth.nhs.uk 69

70 Service Name Achievement Contact Name Contact Number Contact Physical Healthcare Team Name Achievement Contact Name Contact Number Contact Allington and Tarentfort Centre Alpha Hospital Sheffield Ansel Clinic Beech Ward Brockfield House Brooklands Hospital Eaglestone View Cygnet Hospital Bierley Cygnet Hospital Blackheath Cygnet Hospital Kewstoke Bowness Unit 70 The service has a visiting GP who comes onto the ward once a week and can meet with all patients. The service has a female General Practitioner who visits the service every Wednesday. The Psychology department run sessions with patients on both an individual and group basis. 'Talk time' is widely used allowing patients to seek support from members of staff without being in structured sessions. Patients at the service can access a chiropodist, dietician, optician, GP and a smoking cessation group. The service had excellent physical healthcare for patients including a gym, fitness instructor and dietary advice and guidance. The service has strong links with community based primary and secondary care services successfully supporting patients through diagnoses such as cancer and dialysis. Patients have access to a dietician who visits the service on a weekly basis. Patients are seen by the dietician, can access the gym in the evenings and weekends and get smoking cessation advice from the substance misuse practitioner. The service has a voucher incentive programme to encourage patients to engage in exercise. Patients have access to the WISH clinic in the community for contraceptive and sexual health advice and check-ups. It was reported that patients have access to GP, Dentist, Optician, Dietitian and Physiotherapist all within the secure perimeter. Dr Zena Nasser Consultant Psychiatrist Julie Donovan Hospital Director Richard Idle Registered Manager Ian Tearle Deputy Service Line Lead Andy Ward Clinical Nurse Specialist Lesley Wilson Matron Malcolm Campbell Hospital Director Jenny McVinnie Hospital Manager Sharon Fox Clinical Manager David Colyer Hospital Manager Rachel Green Deputy Head of Operations zena.nasser@kmpt.nhs.uk Julie.Donovan@alphaho spitals.co.uk Richard.Idle@cambiang roup.com Ian.tearle@hertspartsft.nhs.uk Andy.ward@sept.nhs.u k Lesley.wilson@covwark pt.nhs.uk MalcolmCampbell@prio rygroup.com jennymcvinnie@cygnet health.co.uk sharonfox@cygnethealt h.co.uk davidcolyer@cygnethea lth.co.uk rachel.green@gmw.nhs.uk

71 Service Name Achievement Contact Name Contact Number Contact Edward House Francis Willis Guild Lodge Kneesworth House Hospital Newton Lodge North London Forensic Service Northgate Hospital Oxford Clinic Ridgeway Shaftesbury Clinic Southview St Magnus Hospital 71 All patients are registered with the local GP and get emergency leave if they do not have the correct leave to visit the GP. The service is in the process of developing physical health flashcards to support with monitoring and early identification of physical health needs. Initial and annual patient screenings are recorded on an electronic system and compliant with NICE guidelines. All patients said they have access to gym sessions, as well as dedicated Well Women and Well Men health clinics. Patients undergo a full assessment of both physical and mental health needs every 6 months. The service has SLAs with local GP, dentist and chiropody. They have access to dieticians and junior doctors also monitor physical health. Patients have access to a GP who runs daily clinics in the afternoon for 2-3 hours. The service has physiotherapist sessions by referral if needed. There is a health centre onsite which has four visiting GPs, one practice nurse, one modern matron, a chiropodist and a physiotherapist. Patients have access to a dentist on site down the corridor from the low secure ward. They can go for emergency appointments or routine check-ups. Patients have a weekly MEWS as part of physical health checks. The unit runs a balance improvement group and a falls clinic. Fiona Thomas Operational Services Manager Jocelyne White Ward Manager Lee Drake Integrated Clinical Manager Linda Ram Head of Social Work & Patient Related Services Catherine Eaves Interim General Manager Low Secure Services Sara Henley Head of Therapies Fiona.thomas@nepft.nh s.uk jocelyne.white@lpft.nhs.uk Shirley Wakefield Service Manager Dr Jude Deacon Head of Low Secure Forensic Service Steve Godwin Deputy Head of Forensic Services Mental Health Kirsty Murray Interim Operational Manager Nick Clark General Manager Dr Patrick O Sullivan Medical Director Lee.drake@lancashirec are.nhs.uk Linda.ram@partnership sincare.co.uk Catherine.eaves@swyt. nhs.uk Shirley.wakefield@ntw. nhs.uk yvonne.rutherford@ntw.nhs.uk Anouschka.Marwick@nt w.nhs.uk Jude.deacon@oxfordhe alth.nhs.uk stephen.godwin@nhs.n et Sara.henley@behmht.nhs.uk Kirsty.murray@swlstgtr.nhs.uk Nick.Clark@sussexpart nership.nhs.uk drosullivan@stmagnus. co.uk

72 Service Name Achievement Contact Name Contact Number Contact Bade Ward The Clee Unit The Spinney Wells Road Centre Wood Lea Clinic There are physical health champions on the low secure ward. The service has access to a dietician and diabetic nurse available to assist patients. There are many health initiatives visible at the service, including the traffic light system at the shop which monitors the amount of unhealthy foods patients can buy at any one time, as well as the successful Shape Up, Trim Down programme. The service outlines healthy eating agreements with patients, supports them to access the onsite gyms and outside equipment, as well as support to quit smoking. Unhealthy snacks are limited. There is a wide range of primary and secondary health care facilities e.g. an ECG monitor to measure heart rates and epilepsy specialists available at Wood Lea Clinic. If additional services are required there are strong links with the local hospital. Shirley Wakefield Service Manager Dr Ram Benning Consultant Forensic Psychiatrist Rena Henderson Lead Occupational Therapist Lorraine Lockley Modern Matron Shona Little Integrated Clinical Lead Shirley.wakefield@ntw. nhs.uk Anouschka.Marwick@nt w.nhs.uk ram.benning@sssft.nhs.uk rena.henderson@partn ershipsincare.co.uk lorraine.lockley@nottsh c.nhs.uk shona.little@sept.nhs.u k Discharge Team Name Achievement Contact Name Contact Number Contact Allington and Tarentfort Centre Arbury Court The service has good links with a range of mainstream activities such as the local gym, dog walking, adult education, golf, fishing, football, bowling and voluntary work. The service works with the next point of care through the CPA and 117 discharge processes. They are able to do video conferencing and patients can invite whoever they want to their meetings. Dr Zena Nasser Consultant Psychiatrist Sue Taylor Lead Nurse zena.nasser@kmpt.nhs.uk Sue.taylor@partnership sincare.co.uk 72

73 Service Name Achievement Contact Name Contact Number Contact Ash Ward Bowman Centre Bracton Centre Bradley Woodlands Chichester Centre Cygnet Hospital Beckton Cygnet Hospital Godden Green 4 Bowlers Green The service is always working towards discharge/transfer as soon as a patient is admitted. Once discharged the consultant follows up with patients after 3 months. The social worker works with patients on independent living. Weekly Trust meetings are attended by a housing charity, landlords and accommodation agencies to plan accommodation for discharge. The service has strong established links with prisons through the London Prison Pathway as well as with community teams. Liaison meetings are held regularly to ensure that these links are maintained for patients once discharged. The service has developed strong links in the community to provide patients with socially inclusive, mainstream activities, including shopping, golfing, fishing, coastal visits and visiting the hairdressers. The service places an emphasis on normalisation and a move away from the forensic label. This is achieved by staff supporting patients in maintaining links with community based organisations. The service has a MAPPA lead who attends quarterly meetings where discharge planning is a regular agenda item. Relationship care plans are completed with patients to identify relationships in support of discharge, for example Family, Care Coordinator, local CMHT, Police, MAPPA, Probation, Local Authority and Housing. The service has a liaison nurse whose role is specifically to work with home area care coordinators and those working for the next point of care to ensure smooth transition in to or out of the service. Colin Reynolds Ward Manager William Fearnley Acting Ward Manager Lisa Dakin Inpatient Service Manager & Head or Nursing Kath Dye Hospital Manager Nick Badoorally Matron Judith Etheridge Hospital Manager Danmore Padare Clinical Manager Ian Tearle Deputy Service Line Lead colin.reynolds@sompar.nhs.uk william.fearnley@nhs.n et Lisa.dakin@oxleas.nhs. uk Kath.dye@lighthousehealthcare.co.uk Nick.badoorally@susse xpartnership.nhs.uk judithetheridge@cygnet health.co.uk danmorepadare@cygne thealth.co.uk Ian.tearle@hertspartsft.nhs.uk 73

74 Service Name Achievement Contact Name Contact Number Contact Farmfield Forest Lodge George MacKenzie House Hazelwood House Hellesdon Humber Centre Kemple View Llanarth Court Hospital Meadow View Newsam Centre North London Clinic Patients are taken to 'Stepping Stones' weekly and community based sports centres. Forensic case manager attends regularly to review progress towards discharge. Patients are tracked on the 12 steps discharge pathway on a weekly basis. Many of the clinical staff work across the low secure and community forensic team maintaining contact with patients as they move through the service. Care coordinators are invited to attend CPA meetings, ward rounds and discharge planning meetings. Meetings are often rearranged to ensure care coordinators are present. Fortnightly clinical reviews and weekly referral meetings address discharges and transfers from the unit. These take a multi-disciplinary approach. Patients are involved in writing and creating a monthly newsletter that is available within the Trust. The service offers Transition Management support and work is done collaboratively with care coordinators and patients. Social workers, care coordinators and offender managers are involved in care planning through CPAs and ICR meetings. The service has a good relationship with commissioners and funders. Social work liaises with family members and can also assist with benefits. Readiness for discharge is addressed through the CPA process, which also includes housing officers for appropriate accommodation placements. There are strong relationships with MAPPA and probation. Police Liaison visit the service twice a year, which has much improved. Lucy Swatling Hospital Director Ajay Pawar Consultant Psychiatrist Wendy Scott-Earl Service Manager, Specialist Services Palmer Chinosengwa Registered Manager Brian Davis Deputy Service Manager Dave King CNS Security Lead Mark Haslam Clinical Nurse Manager Dr Phil Huckle Regional Executive and Clinical Director Stuart Docherty Business Performance Manager Kirstin Gillatt Ward Manager Gary Stobbs Unit Manager sarahhares@priorygrou p.com LucySwatling@priorygr oup.com Ajay.pawar@shsc.nhs.u k Wendy.scottearl@cpft.nhs.uk Palmer.chinosengwa@p artnershipsincare.co.uk Brian.davis@nsft.nhs.u k dave.king@humber.nhs.uk Mark.Haslam@partners hipsincare.co.uk Phil.huckle@partnershi psincare.co.uk sdocherty@caringhome s.org Kirstin.gillatt@nhs.net Gary.stobbs@partnersh ipsincare.co.uk 74

75 Service Name Achievement Contact Name Contact Number Contact Northgate Hospital Rathbone Low Secure Unit Hillis Lodge St Andrew's Healthcare Northampton - CAMHS Service St Andrew's Healthcare Nottinghamshire St John s House LDS Bade Ward Suttons Manor Recovery and Outcomes meetings provide support for patients to develop and maintain links with the community and aids social interactions. The Bridge Builder has brilliant links in the community providing the patient group with access to a range of activities, including; The Brink project, Art and Soul group and a Recovery College. There are strong links with local work based projects such as the BETA pathways project and local leisure facilities. Patients are encouraged to begin making these links pre-discharge. The service works closely with patients to determine their interests and source vocational opportunities as part of their treatment. The police liaison officer works closely with the service. The officer has done clinics where patients have the chance to get to know her. The MDT support patients to develop links with the community through programmes such as the befrienders programme in place with the local village. Bade Ward uses their own forensic community teams and step-down services where possible to prevent delays in discharge. The service takes patients out into the community every Friday afternoon. Patients can choose where they want to go. This can be bowling, to a museum or go on home leave. Shirley Wakefield Service Manager Sara Finlayson Head of Psychological Services Jan Morris Service Development Manager David Rodgers Ward Manager Lisa Powell Hospital Director Fungai Nhiwatiwa Unit Manager Shirley Wakefield Service Manager Pat Khek Clinical Services Manager Shirley.wakefield@ntw. nhs.uk yvonne.rutherford@ntw.nhs.uk Anouschka.Marwick@nt w.nhs.uk sara.finlayson@mersey care.nhs.uk Jan.morris@bsmhft.nhs.uk drodgers@standrew.co. uk lpowell1@standrew.co. uk fungai.nhiwatiwa@part nershipsincare.co.uk Shirley.wakefield@ntw. nhs.uk Anouschka.Marwick@nt w.nhs.uk Pat.khek@partnershipsi ncare.co.uk 75

76 Service Name Achievement Contact Name Contact Number Contact Wells Road Centre Wood House The service has good links with MAPPA and the local Victim Liaison Team, parole processes and the Forensic Community Team for effective and long lasting discharges. Patients have care coordinators and representatives from NHS England who attend their CPA meetings. Lorraine Lockley Modern Matron Simon Reed Hospital Manager c.nhs.uk -healthcare.co.uk 76

77 Service Name Achievement Contact Name Contact Number Contact A Safe and Therapeutic Environment Physical Security Team Name Achievement Contact Name Contact Number Contact Beech House Hospital Beech Ward Bracton Centre Cygnet Hospital Stevenage Farmfield Foxhall House Francis Willis Ellesmere House Kemple View 77 All keys are held securely at reception and exchanged within the airlock. Staff hand over their ID badges in exchange for keys. The system is computerised and there is a key tracking system in place. Keys have a tag system which will trigger an alarm if removed. There is meet the team information on display to identify staff prior to access onto the ward. The service is using a tracker system to account for keys and reports are run twice a day. The service ensures keys are checked up to 4 times a day. The patients have freedom of movement within the internal perimeter. They all have free access to their bedrooms and the kitchen to make hot drinks and snacks and can use the cold drinks dispenser. The service involves patients in risk assessments where possible and have developed self-report risk assessments for patients to complete pre and post leave. Keys are traceable by time, member of staff, date and length of keys being out (more than 16 hours would alert manager). Access to keys are limited by a staff-specific code that only allows the staff member s own set of keys to be released. Fobs are issued and accounted for at the main reception and staff access keys based on the wards with individualised codes. Keys are typed and these refer to levels of access around the site. David Lewis Hospital Manager Ian Tearle Deputy Service Line Lead Lisa Dakin Inpatient Service Manager & Head or Nursing Joe Thomas Interim Hospital Manager Lucy Swatling Hospital Director Brian Davis Deputy Service Manager Jocelyne White Ward Manager Dr Jayanth Srinivas Clinical Director & Julie Robbie PA Mark Haslam Clinical Nurse Manager david.lewis@huntercom be.com Ian.tearle@hertspartsft.nhs.uk Lisa.dakin@oxleas.nhs. uk josephthomas@cygneth ealth.co.uk sarahhares@priorygrou p.com LucySwatling@priorygr oup.com Brian.davis@nsft.nhs.u k jocelyne.white@lpft.nhs.uk jayanth.srinivas@sssft. nhs.uk julie.robbie@nhs.net Mark.Haslam@partners hipsincare.co.uk

78 Service Name Achievement Contact Name Contact Number Contact Langdon Hospital Morris Ward North London Clinic St Andrew's Healthcare Essex St Andrew's Healthcare Northampton - CAMHS Service St Magnus Hospital St Mary s Hospital Suttons Manor The Clee Unit The service uses electronic meet the team and information boards based within the airlocks on each ward. The perimeter fence was noted to be made up of both a wire fence to low secure specification and sandwiched between close set wooden fencing ensuring privacy and removing all possible climb points. Ward staff reported that ligature points are well managed and that each ward has a Health and Safety Champion and a security nurse available on every shift. The reception is manned for 24 hours a day. All keys are controlled, issued and accounted for by reception. They are accounted for three times a day, and once further to check the condition of the keys. The service uses the Paxton key management system where all fobs are registered to individual members of staff and the fob links to a computer to identify exactly where staff members are within the unit. All staff must undergo a key test and score 100% before being issued with keys. The Morse Watchman key management system checks the keys automatically and the security lead checks the keys on a random basis. The fencing that forms the secure external perimeter of the unit is a minimum height of three meters and is surrounded by anti-climb mechanisms. Julie Donaghue Business Manager Kristoff Bonello Clinical Lead Psychologist Gary Stobbs Unit Manager Amanda Spooner Lead Nurse David Rodgers Ward Manager Dr Patrick O Sullivan Medical Director Christine Walker Deputy Hospital Manager Pat Khek Clinical Services Manager Wayne Harvey Forensic Security Manager j.donaghue@nhs.net ext kristoff.bonello@nelft.n hs.uk Gary.stobbs@partnersh ipsincare.co.uk aspooner@standrew.co.uk EGallivan@standrew.co.uk drodgers@standrew.co. uk drosullivan@stmagnus. co.uk christinewalker@stgeor gehealthcaregroup.co.u k Pat.khek@partnershipsi ncare.co.uk wayne.harvey@sssft.nh s.uk 78

79 Service Name Achievement Contact Name Contact Number Contact The Orchard The Spinney Wood House Woodlands House The service maintains good privacy through the black fence but the mesh topping allows natural light still to enter the garden. Health and Safety Representatives on wards allow for clear reporting on any identified ligature points, with immediate action. All patients have freedom of movement within the internal perimeter area. Patient's bedroom doors are left open and they have access to the kitchen using their own swipe cards. Areas accessible by most clinically unwell patients have an increased fence height of five metres. Doreen Whande Senior Nurse Rena Henderson Lead Occupational Therapist Simon Reed Hospital Manager Preeteema Gungah Ward Manager ershipsincare.co.uk -healthcare.co.uk ordhealth.nhs.uk Relational Security Team Name Achievement Contact Name Contact Number Contact All Saints Allington and Tarentfort Centre Alpha Hospital Woking Ansel Clinic The service offers British Sign Language training Levels 1-3 to all staff and patients. The service has links with the University of Greenwich where patients are employed to be patients for student nurses to gain experience. The patients then rate the student on how well they did. Patients can also work in the canteen on site and do jobs on their ward. The organisation has a designated website for staff to provide anonymous feedback. The service encourages patient involvement in education and is an examining centre and can provide qualifications for patients in food hygiene, cookery and gardening. Bernadette McCafferty Registered Manager Dr Zena Nasser Consultant Psychiatrist Sam Antwi-Marful Hospital Director Richard Idle Registered Manager MarieMcCafferty@stgeo rgehealthcaregroup.co. uk Cc in SamanthaTattersall@st georgehealthcaregroup. co.uk zena.nasser@kmpt.nhs.uk Sam.Antwi- Marful@alphahospitals. co.uk Richard.Idle@cambiang roup.com 79

80 Service Name Achievement Contact Name Contact Number Contact Ash Ward Bowman Centre Burston House Maplewood West Drive Cedar House Eaglestone View Cheswold Park Hospital Cygnet Hospital Derby Cygnet Hospital Godden Green The service has access to Bridgwater College as well as Angel Place which is smaller than Bridgwater College for patients who feel overwhelmed at the bigger college. The service has good links with community organisations providing real opportunities to work, including; bike maintenance, furniture restoration and computer courses. There is a Partnerships in Care programme for real work opportunities. The service has developed it for their LD service. This programme helps patients develop the skills needed for applying for a job. The service is working from the Positive and Safe Agenda which encourages staff to identify positive aspects from each shift during handover. The service employs a vocational rehabilitation coordinator and other professionals are available through the Our Shared College and the local college. The service s education department is a registered ASDAN centre and the service has a teacher and teaching assistant. The service has handovers which take place for 30 to 45 minutes and there is an electronic handover. Incidents and issues are discussed and debriefed within reflective practice group sessions. The service has links with the local college and university where patients can access e-learning courses as well as a visiting Music Teacher and educational tutor. Development Days were noted by staff to be key in understanding relational security and gaining a shared understanding of each patient. Colin Reynolds Ward Manager William Fearnley Acting Ward Manager Fungai Nhiwatiwa Hospital Director Lynne Kirwan Operational Support Manager Lynne Kirwan Operational Support Manager Emma Harrison Hospital Manager Malcolm Campbell Hospital Director David Williams Director of Nursing Mark Varney Hospital Manager Danmore Padare Clinical Manager colin.reynolds@sompar.nhs.uk william.fearnley@nhs.n et fungai.nhiwatiwa@part nershipsincare.co.uk lynne.kirwan@calderso nes.nhs.uk lynne.kirwan@calderso nes.nhs.uk emma.harrison@hunter combe.com MalcolmCampbell@prio rygroup.com dwilliams@cheswoldpar khospital.co.uk markvarney@cygnethe alth.co.uk danmorepadare@cygne thealth.co.uk 80

81 Service Name Achievement Contact Name Contact Number Contact Cygnet Hospital Stevenage 4 Bowlers Green Forest Lodge Foxhall House Ellesmere House Hollins Park Hospital Llanarth Court Hospital Llanarth Court Hospital There are a range of in-house and external vocational opportunities with a vocational pathway that includes applications, interviews and skill development, in house roles such as maintenance support and housekeeping or running the shop to external roles on a local farm, shop work or local voluntary sector placements. The service has a full time teacher and teaching assistant to support the educational needs of patients as well as having developed strong links with local colleges. The service has access to a tutor who comes in to the service to offer English and Maths lessons to patients. All staff have weekly reflective practice sessions where they can discuss issues of relational security. The service offers OCN courses to GCSE level. Patients are also attending Stafford College and QUEST courses to build skills. There are also Trust wide initiatives within the community and patients are referred on to these. The service has a good mix of staff trained in both LD and mental health. The modern matron is RNLD trained and so are most of the staff on Auden ward. The service has a therapeutic training day every month which is available to all clinical staff as well as any staff who are nominated by the charge nurse to go for extra training or anyone who feels they need it. The service has two members of staff who are accredited Forensic Psychotherapists who are trained in psychodynamic and psychoanalytic therapy and facilitate supervision, assessment and reflective practice at the service. Joe Thomas Interim Hospital Manager Ian Tearle Deputy Service Line Lead Ajay Pawar Consultant Psychiatrist Brian Davis Deputy Service Manager Dr Jayanth Srinivas Clinical Director & Julie Robbie PA Sue Lee Modern Matron - Secure Services Dr Phil Huckle Regional Executive and Clinical Director Dr Phil Huckle Regional Executive and Clinical Director josephthomas@cygneth ealth.co.uk Ian.tearle@hertspartsft.nhs.uk Ajay.pawar@shsc.nhs.u k Brian.davis@nsft.nhs.u k jayanth.srinivas@sssft. nhs.uk julie.robbie@nhs.net Sue.lee@5bp.nhs.uk Phil.huckle@partnershi psincare.co.uk Phil.huckle@partnershi psincare.co.uk 81

82 Service Name Achievement Contact Name Contact Number Contact Newsam Centre North London Forensic Service Oaktree Manor Rathbone Low Secure Unit Clare Ward Southview St Andrew's Healthcare Essex St Andrew's Healthcare Nottinghamshire Suttons Manor Relational security meetings and discussions occur through many forums, including: supervision, reflective practice, community meetings and Presentation of Risk Groups with patient involvement. There are regular meetings where staff discuss and reflect on relational security issues. These occur in See, Think, Act groups, reflective practice and group supervision. All staff have access to an active dashboard which provides up-to-date information on the service, the patient group and the ward environment. The service pays patients to sit on interview panels and do meet and greet roles. They are also training patients for peer-support worker roles. The service works in partnership with EXTERN to provide external training opportunities in upholstery, ICT, Literacy and Numeracy. There is an extensive range of vocational opportunities available to patients including working at Badgers Café. These roles are paid and NVQ qualifications can be completed. The patients do ward based jobs such as gardening, admin roles and cleaning. Handovers occur during protected time. The service has strong links with community organisations such as Sainsbury s, Lambourne End Activity Centre and Essex Wildlife Trust. Patients have the opportunity to volunteer at these centres. Kirstin Gillatt Ward Manager Sara Henley Head of Therapies Beatrice Nyamande Registered Manager Sara Finlayson Head of Psychological Services Noel McDonald Operations Manager Nick Clark General Manager Amanda Spooner Lead Nurse Lisa Powell Hospital Director Pat Khek Clinical Services Manager rtnershipsincare.co.uk care.nhs.uk trust.hscni.net nership.nhs.uk uk ncare.co.uk 82

83 Service Name Achievement Contact Name Contact Number Contact The Dene The service has a real work opportunities programme in place with 15 paid job roles on offer, including painting and decorating. Alexandra Thurlby Hospital Director Alexandra.thurlby@part nershipsincare.co.uk Tony Hillis Wing Wood Lea Clinic Woodlands House Staff reported the handovers to be informative and contain details about each patients section, index offence and additional important information as well as events occurring in the past 24 hours. Every 3-6 months there is a staff away day focusing on relational security. The service has diversified See, Think, Act to incorporate images and case studies to enhance training for staff. Dawn Harwood Head of Service Shona Little Integrated Clinical Lead Preeteema Gungah Ward Manager Dawn.harwood@wlmht. nhs.uk shona.little@sept.nhs.u k Preeteema.gungah@oxf ordhealth.nhs.uk Procedural Security Team Name Achievement Contact Name Contact Number Contact All Saints Alpha Hospital Bury Arbury Court Beech House Hospital 83 Interpreters are provided for deaf staff members to help them understand the policies in place around procedural security. Policies are made as accessible as possible to deaf staff and patients. Provisions for caring for patients in seclusion are well thought out at the service. There is a seclusion management group who review seclusion issues which are then taken to governance. Behavioural Support Plans are identified through the use of My Shared Pathway and these detail how patients would like to be treated in the event of seclusion. The service provides restraint care plans which are individualised and reviewed if they have to restrain a patient. Patients have access to a clear complaints procedure, with an attached form that is filled out in the patient s own words, with the help of staff or the advocate. Bernadette McCafferty Registered Manager Charlotte Garvey Head of Care Sue Taylor Lead Nurse David Lewis Hospital Manager MarieMcCafferty@stgeo rgehealthcaregroup.co. uk Cc in SamanthaTattersall@st georgehealthcaregroup. co.uk charlotte.garvey@alpha hospitals.co.uk Sue.taylor@partnership sincare.co.uk david.lewis@huntercom be.com

84 Service Name Achievement Contact Name Contact Number Contact Burston House Cygnet Hospital Beckton Cygnet Hospital Blackheath Cygnet Hospital Derby Gerry Simon Clinic Hollins Park Hospital Kneesworth House Hospital Clare Ward St Andrew's Healthcare Northampton- Men's Service St Mary s Hospital The service has a policy in place regarding recording and reporting crimes which is specific to their LD service. There is a policy in place around patient access to the internet. Patients have access to Skype in the shared ward area and on Berwick ward. Patients have their own address. There is a clear complaints procedure which was reported by patients as being responsive and fastacting. Where risks are identified in a patient s offending history or personal background an individualised prevention management violence aggression (PMVA) care plan is drawn up by multi-disciplinary team. Patients understand how to make a complaint via the PALS suggestions box which is in the activities area. Policies regarding restraint and seclusion address the potential requirement for individualised care needs. This is called Positive Support Cycle. The service is working towards implementing a Positive Behaviour Strategy which aims to reduce the use of restraint and seclusion. A copy of the banned items policy is provided in the welcome area of the unit and is also sent to family and friends as part of the carer induction booklet. BSL courses are offered at levels 1 and 2 to staff at St Andrew s. The service gives one-to-one time to deaf patients to help them understand policies. Fungai Nhiwatiwa Hospital Director Judith Etheridge Hospital Manager Sharon Fox Clinical Manager Mark Varney Hospital Manager Dr Joseph Vella Consultant Psychiatrist Sue Lee Modern Matron - Secure Services Linda Ram Head of Social Work & Patient Related Services Noel McDonald Operations Manager Lynn Baxter Hospital Director Christine Walker Deputy Hospital Manager fungai.nhiwatiwa@part nershipsincare.co.uk judithetheridge@cygnet health.co.uk sharonfox@cygnethealt h.co.uk markvarney@cygnethe alth.co.uk joe.vella@bcpft.nhs.uk Sue.lee@5bp.nhs.uk Linda.ram@partnership sincare.co.uk noel.mcdonald@belfast trust.hscni.net lbaxter@standrew.co.u k christinewalker@stgeor gehealthcaregroup.co.u k 84

85 Service Name Achievement Contact Name Contact Number Contact The Spinney Thornford Park Hospital Wells Road Centre There is a policy on the prosecution of offences within the unit which is agreed in line with the police and CPS. The service has close relationships with the local Police Liaison team to establish policies. Policies regarding restraint and seclusion take into account physical healthcare needs. Seclusion care plans are implemented as soon as a patient enters seclusion, as well as post incident de-briefing in collaboration with advocacy. Rena Henderson Lead Occupational Therapist Paul O Connor Regional Hospital Director Lorraine Lockley Modern Matron rena.henderson@partn ershipsincare.co.uk pauloconnor@priorygro up.com cc in DawnJeffries@priorygro up.com lorraine.lockley@nottsh c.nhs.uk 85

86 Service Name Achievement Contact Name Contact Number Contact Service Environment Team Name Achievement Contact Name Contact Number Contact Alpha Hospital Bury Alpha Hospital Sheffield Beech House Hospital Beech Ward Bradley Woodlands Brockfield House Brooklands Hospital Maplewood Eaglestone View Clifton House 86 Patients are very much involved in the paintings and murals across the wards and staff were said to be proud of the outcomes. The service has excellent child visiting facilities. There is a baby changing facility next to reception and a hot drinks machine installed in the visiting area. The service provides practical support for friends and families regarding travelling to the service. \the service also goes to great lengths in order to accommodate leave for family events such as weddings, when applicable. The service has boxes of religious texts within their multi-faith room and a Chaplain visits the service every Wednesday. There is a garden area external to the secure perimeter where patients can do horticultural projects, gardening and grow their own vegetables. Patients have the opportunity to review and contribute to HCR-20 Version 3. Recent renovations have resulted in high specification furniture suitable for the unit environment. Staff will often collect families from the train station. Some patients have their visits home funded. HCR-20 and SAPROF are used at the service. The service is currently looking to make a more collaborative process. The service has an excellent child visiting area with toys and a good outside space. Charlotte Garvey Head of Care Julie Donovan Hospital Director David Lewis Hospital Manager Ian Tearle Deputy Service Line Lead Kath Dye Hospital Manager Andy Ward Clinical Nurse Specialist Lesley Wilson Matron Lynne Kirwan Operational Support Manager Malcolm Campbell Hospital Director Mark Dodd Matron & Mike Waldie Ward Manager charlotte.garvey@alpha hospitals.co.uk Julie.Donovan@alphaho spitals.co.uk david.lewis@huntercom be.com Ian.tearle@hertspartsft.nhs.uk Kath.dye@lighthousehealthcare.co.uk Andy.ward@sept.nhs.u k Lesley.wilson@covwark pt.nhs.uk lynne.kirwan@calderso nes.nhs.uk MalcolmCampbell@prio rygroup.com Mark.dodd2@nhs.net Mike.waldie@nhs.net

87 Service Name Achievement Contact Name Contact Number Contact Cygnet Hospital Bierley Cygnet Hospital Blackheath Cygnet Hospital Godden Green Cygnet Hospital Harrow Cygnet Hospital Kewstoke Cygnet Hospital Stevenage Bowness Unit Edward House Forest Lodge Foxhall House Hellesdon Lee Mill Unit The service has excellent outside space decorated with Murals with lots of seating and a basketball court. The service has a poem/story of the day board and a motivational quotes board. Patients hold key fobs which are used to open and lock individual bedrooms. Patients also have lockers in which to keep mobile phones and cigarettes. The service is able to support the financial implications of travel for carers and family members. There is onsite accommodation for family members who live a distance from the service to stay overnight. Patients have access to a small safe in their bedrooms for personal possessions and medication if self-medicating. The section 17 leave process was praised where patients fill out a confirmation form to describe their clothing, allowing them to take responsibility of their own leave. The patient and staff environment is very light, bright and homely and the environment was clean and well laid out. The service works with families through the family intervention work offered based on a psychoeducational approach. The service can help with carer and patient expenses to allow them to visit their loved ones. Skype calls can also be facilitated. There is Skype access for families who live a significant distance away from the service. Patients have access to a telephone in a private area, as well as basic mobile phones. Jenny McVinnie Hospital Manager Sharon Fox Clinical Manager Danmore Padare Clinical Manager Seamus Quigley Hospital Manager David Colyer Hospital Manager Joe Thomas Interim Hospital Manager Rachel Green Deputy Head of Operations Fiona Thomas Operational Services Manager Ajay Pawar Consultant Psychiatrist Brian Davis Deputy Service Manager Brian Davis Deputy Service Manager Jane Quigley Ward Manager jennymcvinnie@cygnet health.co.uk sharonfox@cygnethealt h.co.uk danmorepadare@cygne thealth.co.uk seamusquigley@cygnet health.co.uk davidcolyer@cygnethea lth.co.uk josephthomas@cygneth ealth.co.uk rachel.green@gmw.nhs.uk Fiona.thomas@nepft.nh s.uk Ajay.pawar@shsc.nhs.u k Brian.davis@nsft.nhs.u k Brian.davis@nsft.nhs.u k janequigley@nhs.net 87

88 Service Name Achievement Contact Name Contact Number Contact Morris Ward Newton Lodge North London Forensic Service Northgate Hospital Oxford Clinic Ridgeway Robin Pinto Unit Saddlebridge Recovery Centre & Alderley Unit Shaftesbury Clinic St Andrew's Healthcare Birmingham St Andrew's Healthcare Northampton - Women's Service 88 The service has access to a multi-faith room which has a wide range of religious paraphernalia including a marker to locate Mecca. The service has created a risk assessment called RAMP on the low secure wards which patients are included in. It is a collaborative risk assessment. The service has access to a number of community faith leaders who attend the service to hold prayer sessions for patients. The service has a Getting to Know You scheme that invites visitors to give feedback and create plans with carers about how they would like to be contacted by the service. Carers are consulted regarding the clinical model. Carers have been given a tour of the ward areas to encourage more involvement and interaction. There is a separate child visiting room with access to a kitchen area and WC. There are games and activities appropriate for children of all ages, a TV, seating, a highchair and an outside courtyard. It is a Trust policy to support payment for public transport for carers if needed. The ward is bright and welcoming. Each ward has been painted in themed colours and has wall coverings of beach and sea scenes. Patients are offered training and education on risk assessments as part of CQUIN targets. The peer-review team were impressed by the facilities within the multi faith room, including a foot wash, a prayer mat and other religious artefacts. The service uses the HCR-20, START, HONOS and SDRS. Kristoff Bonello Clinical Lead Psychologist Catherine Eaves Interim General Manager Low Secure Services Sara Henley Head of Therapies ext Shirley Wakefield Service Manager Dr Jude Deacon Head of Low Secure Forensic Service Steve Godwin Deputy Head of Forensic Services Mental Health Shona Little Integrated Clinical Lead Dave Jones Clinical Service Manager Kirsty Murray Interim Operational Manager Victoria Hitch Lead Occupational Therapist Dr Samudra Sarkar Consultant Psychiatrist kristoff.bonello@nelft.n hs.uk Catherine.eaves@swyt. nhs.uk Shirley.wakefield@ntw. nhs.uk yvonne.rutherford@ntw.nhs.uk Anouschka.Marwick@nt w.nhs.uk Jude.deacon@oxfordhe alth.nhs.uk stephen.godwin@nhs.n et shona.little@sept.nhs.u k david.jones@cwp.nhs.u k Sara.henley@behmht.nhs.uk Kirsty.murray@swlstgtr.nhs.uk vhitch@standrew.co.uk Ssarkar@standrew.co.u k

89 Service Name Achievement Contact Name Contact Number Contact St Andrew's Healthcare Northampton - Women's Service St John s House LDS St Mary s Hospital Bade Ward All low secure wards had their own access to visiting rooms as well as baby changing facilities. It was reported that patients are mood assessed prior to accessing garden areas. The service provides support to family and friends by paying travel costs and funding a hotel stay if they are travelling a long way. There is a carers evening offered in which patients are invited to talk about their experiences. Dr Samudra Sarkar Consultant Psychiatrist Fungai Nhiwatiwa Unit Manager Christine Walker Deputy Hospital Manager Shirley Wakefield Service Manager Ssarkar@standrew.co.u k fungai.nhiwatiwa@part nershipsincare.co.uk christinewalker@stgeor gehealthcaregroup.co.u k Shirley.wakefield@ntw. nhs.uk Anouschka.Marwick@nt w.nhs.uk The Dene The ward environment is light and bright and has many pictures up on the ward, including photographs and pictures created by the patients. Alexandra Thurlby Hospital Director Alexandra.thurlby@part nershipsincare.co.uk Thornford Park Hospital Thornford Park Hospital Wood House Theale Ward has won a Koestler Award for patients being involved in decorating Theale ward. Families and friends can apply for financial assistance with travel and the use of Skype has enabled additional methods of communication for families. The service has a good relationship with carers. The hospital manager does a carers newsletter and they provide transport plans for visiting. Paul O Connor Regional Hospital Director Paul O Connor Regional Hospital Director Simon Reed Hospital Manager pauloconnor@priorygro up.com DawnJeffries@priorygro up.com pauloconnor@priorygro up.com DawnJeffries@priorygro up.com Simon.reed@lighthouse -healthcare.co.uk 89

90 Service Name Achievement Contact Name Contact Number Contact Workforce Team Name Achievement Contact Name Contact Number Contact Alpha Hospital Bury Alpha Hospital Woking Amber Lodge Ansel Clinic Bowman Centre Burston House Maplewood Cedar House Cheswold Park Hospital Cygnet Hospital Bierley Cygnet Hospital Derby Supervision passports are carried by all members of staff and focus groups take place as added support for staff. Staff receive supervision on a monthly basis and individuals can approach their supervisor for additional sessions. All patients have copies of the Valuing People Now purple folders. Staff receive supervision once a month, including group supervision and informal support. Supervision is logged and reported to management regularly. Supervision is recorded on supervision passports. Epilepsy and autism spectrum conditions are included as part of the role based training which staff complete. The service receives monthly visits from Women in Secure Hospitals (WISH) and they deliver training around issues affecting the female patient group. There is a training co-ordinator who records all training needs for the staff team and plans training for the next year. Two members of staff are trained to deliver person centred planning training. The service has a good multi-disciplinary team who have regular meetings. If one member cannot attend the service provides summary sheets for them. Staff receive both management and clinical supervision and time is protected for all staff. Charlotte Garvey Head of Care Sam Antwi-Marful Hospital Director Louisa Endersby Assistant Director Forensic Services Richard Idle Registered Manager William Fearnley Acting Ward Manager Fungai Nhiwatiwa Hospital Director Lynne Kirwan Operational Support Manager Emma Harrison Hospital Manager David Williams Director of Nursing Jenny McVinnie Hospital Manager Mark Varney Hospital Manager charlotte.garvey@alpha hospitals.co.uk Sam.Antwi- Marful@alphahospitals. co.uk Louisa.endersby@rdash.nhs.uk Richard.Idle@cambiang roup.com william.fearnley@nhs.n et fungai.nhiwatiwa@part nershipsincare.co.uk lynne.kirwan@calderso nes.nhs.uk emma.harrison@hunter combe.com dwilliams@cheswoldpar khospital.co.uk jennymcvinnie@cygnet health.co.uk markvarney@cygnethe alth.co.uk 90

91 Service Name Achievement Contact Name Contact Number Contact 4 Bowlers Green Farmfield Forest Lodge Wickham Unit George MacKenzie House Guild Lodge Humber Centre Kneesworth House Hospital Langdon Hospital Langdon Hospital Llanarth Court Hospital The service has a central data base that all staff have access to showing individual, ward and service level compliance rates with training, including mandatory/essential training and discipline specific. The SMS system is run from reception, which helps with securing bank staff. The service makes great efforts to recruit and stage assessment centres once a month. There is an annually reviewed training and development strategy including Away days at Home four times per year focusing on service specific training needs and updates for all staff. The service has good links with epilepsy services. Security training is managed and must be signed off by security leads before keys are issued. Six monthly/annual refreshers are also in place. Staff work cohesively together, working longer hours and providing cover where necessary, to maintain a safe environment. The service has access to Epilepsy services within the Trust at Hull Royal Hospital and delivers training to staff. Staff undergo six hours of training every two months, which includes one hour of protected supervision. The peer review team particularly liked the you said, we did boards displayed on each ward demonstrating how staff have responded to patient feedback. Supervision is monitored on a weekly and monthly basis with the unit running at 80-90% uptake % of all staff completed their mandatory training and the service won an award for the training. Ian Tearle Deputy Service Line Lead Lucy Swatling Hospital Director Ajay Pawar Consultant Psychiatrist Julie Somerville Lead Occupational Therapist Wendy Scott-Earl Service Manager, Specialist Services Lee Drake Integrated Clinical Manager Dave King CNS Security Lead Linda Ram Head of Social Work & Patient Related Services Julie Donaghue Business Manager Julie Donaghue Business Manager Dr Phil Huckle Regional Executive and Clinical Director Ian.tearle@hertspartsft.nhs.uk sarahhares@priorygrou p.com LucySwatling@priorygr oup.com Ajay.pawar@shsc.nhs.u k julie.somerville@nhs.ne t Wendy.scottearl@cpft.nhs.uk Lee.drake@lancashirec are.nhs.uk dave.king@humber.nhs.uk Linda.ram@partnership sincare.co.uk j.donaghue@nhs.net j.donaghue@nhs.net Phil.huckle@partnershi psincare.co.uk 91

92 Service Name Achievement Contact Name Contact Number Contact Morris Ward Newton Lodge North London Clinic Oaktree Manor Ridgeway River House Southview St Andrew's Healthcare Essex St John s House LDS All staff complete a local induction prior to receiving secure keys which incorporates the three domains of security. All staff attend a Trust induction and have an induction pack to complete within the first three months of service. The service has access to an epilepsy specialist trained nurse and a neurologist. The Responsible Clinician is also trained in epilepsy. There is a dynamic approach to supervision at the service, with two nursing reflections and one MDT reflection in place. All staff have their own training matrix in order to track their training needs and identify areas for development. An Electronic Staff Record (ESR) records all of the staff information and works collaboratively with an Integrated Information Centre (ICC) system which holds training records accessible by the service and individual staff member. Patient s perspective is included in the management of violence training and My Shared Pathways meetings and training. Staff receive security training as part of their induction. If staff fail to complete mandatory updates, keys are temporarily removed until training is complete and passed. The service has a bureau system to source extra nursing cover and they provide supervision for their bank staff. A training needs analysis is done for each service to ensure training in appropriate specialist areas is completed. Kristoff Bonello Clinical Lead Psychologist Catherine Eaves Interim General Manager Low Secure Services Gary Stobbs Unit Manager Beatrice Nyamande Registered Manager Steve Godwin Deputy Head of Forensic Services Mental Health Ellie Bateman Service Director Nick Clark General Manager Amanda Spooner Lead Nurse Fungai Nhiwatiwa Unit Manager ext kristoff.bonello@nelft.n hs.uk Catherine.eaves@swyt. nhs.uk Gary.stobbs@partnersh ipsincare.co.uk Beatrice.nyamande@pa rtnershipsincare.co.uk stephen.godwin@nhs.n et Eleanor.Bateman@slam.nhs.uk Nick.Clark@sussexpart nership.nhs.uk aspooner@standrew.co.uk EGallivan@standrew.co.uk fungai.nhiwatiwa@part nershipsincare.co.uk 92

93 Service Name Achievement Contact Name Contact Number Contact Suttons Manor The service monitors staff training records via an electronic traffic light system which alerts staff when they are due to renew their training. This is also the case for their supervision and appraisals. Pat Khek Clinical Services Manager ncare.co.uk 93

94 Service Name Achievement Contact Name Contact Number Contact Governance Team Name Achievement Contact Name Contact Number Contact All Saints Allington and Tarentfort Centre Amber Lodge Bracton Centre Brockfield House Burston House Cygnet Hospital Godden Green Cygnet Hospital Harrow Cygnet Hospital Kewstoke The service holds meetings with other Trusts who offer specialist deaf services to discuss issues around incidents and lessons learned and sharing of this information. The service has links with the police liaison officer who visits the ward. They have an emergency protocol in operation. If an emergency occurs the emergency service will respond immediately. The Trust has a dedicated lead for emergency planning who carries out regular desktop exercises. A quarterly newsletter highlighting serious and untoward incidents (SUIs) and lessons learned is produced and disseminated to all ward staff. Desktop exercises are conducted annually which is facilitated by the Head of Organisational Resilience & Business Continuity. The service has 80 contingency plans on Partnerships in Care s list which includes live and desktop exercises. Learning from incidents is shared through governance meetings with frontline staff having sight of any relevant action plans. The service pulls expertise and support from other Cygnet Hospitals for the investigation of SUIs. New members of staff at the local fire and police services are invited for a tour of the unit to familiarise themselves with the ward layout. Bernadette McCafferty Registered Manager Dr Zena Nasser Consultant Psychiatrist Louisa Endersby Assistant Director Forensic Services Lisa Dakin Inpatient Service Manager & Head or Nursing Andy Ward Clinical Nurse Specialist Fungai Nhiwatiwa Hospital Director Danmore Padare Clinical Manager Seamus Quigley Hospital Manager David Colyer Hospital Manager MarieMcCafferty@stgeo rgehealthcaregroup.co. uk Cc in SamanthaTattersall@st georgehealthcaregroup. co.uk zena.nasser@kmpt.nhs.uk Louisa.endersby@rdash.nhs.uk Lisa.dakin@oxleas.nhs. uk Andy.ward@sept.nhs.u k fungai.nhiwatiwa@part nershipsincare.co.uk danmorepadare@cygne thealth.co.uk seamusquigley@cygnet health.co.uk davidcolyer@cygnethea lth.co.uk 94

95 Service Name Achievement Contact Name Contact Number Contact Edward House 4 Bowlers Green Wickham Unit Humber Centre Wolfston House Kemple View Kneesworth House Hospital Langdon Hospital Lee Mill Unit Meadow View The service has action plans to identify trends. They have a senior management team meeting once a month where they discuss SUIs. This is then disseminated to staff in regular team meetings and they use handovers to discuss any issues raised. Learning from incidents is shared through 24 hour handover meetings, s, governance structures and directorate wide meetings. The service is involved in a regional quality network for NHS England to invite and information share with neighbouring services to learn and network information. The Risk Management Group organises investigations with action planning being brought to governance team meetings. The Metropolitan Police provide hostage and negotiation training to staff at the service and there are also links with Hackney police and the fire brigade. The service maintains agreements with local secure units regarding the transfer of patients in cases where there has been serious incidents. The service has produced a booklet about the meaning of governance, detailing how both staff and patients can be involved. Serious and untoward incidents are continually monitored. The unit has an annual meeting to discuss action points and outcomes from the previous year s incidents and lessons learned. The service has an SUI Newsletter for all staff to read. The service attends an East of England Security group where shared learning is maintained. Fiona Thomas Operational Services Manager Ian Tearle Deputy Service Line Lead Julie Somerville Lead Occupational Therapist Dave King CNS Security Lead Deborah Bull Deputy Head of Service Mark Haslam Clinical Nurse Manager Linda Ram Head of Social Work & Patient Related Services Julie Donaghue Business Manager Jane Quigley Ward Manager Stuart Docherty Business Performance Manager Fiona.thomas@nepft.nh s.uk Ian.tearle@hertspartsft.nhs.uk julie.somerville@nhs.ne t dave.king@humber.nhs.uk Debbie.Bull@eastlondo n.nhs.uk Mark.Haslam@partners hipsincare.co.uk Linda.ram@partnership sincare.co.uk j.donaghue@nhs.net janequigley@nhs.net sdocherty@caringhome s.org 95

96 Service Name Achievement Contact Name Contact Number Contact Newsam Centre Newton Lodge North London Forensic Service Northgate Hospital Hillis Lodge Robin Pinto Unit Southfield Low Secure Unit Southview St Andrew's Healthcare Birmingham St Andrew's Healthcare Northampton- Men's Service The service uses a DATIX system to locally analyse data to enhance learning and communication on site. The service performed a live fire brigade exercise in the past 24 months. The service does monthly SUI meetings to review and study SUI reports. There are separate learning the lessons meetings set up wherever necessary. There is a monthly CLIP Report that breaks down incidents into themes and these are shared around the service. There is a lessons learned poster produced monthly which centres around a key theme and designed in a fun yet informative way. Every patient has a carer s assessment to determine what family and friend s involvement is permitted. Testing of contingency plans is reviewed annually. The service meets with the police to arrange the need for desktop and live exercises. They do fire drills and suicide scenarios which involve a selection of staff. Tabletop and live exercises are completed on a regular basis. These are conducted in association with the fire, ambulance and police services. The patients safety group meets on a regular basis. Lessons learnt are disseminated through the patients meeting minutes. Lessons learnt are discussed at the Patients Safety Group. Kirstin Gillatt Ward Manager Catherine Eaves Interim General Manager Low Secure Services Sara Henley Head of Therapies Kirstin.gillatt@nhs.net Shirley Wakefield Service Manager Jan Morris Service Development Manager Shona Little Integrated Clinical Lead Dr Luke Birmingham Consultant Forensic Psychiatrist Nick Clark General Manager Victoria Hitch Lead Occupational Therapist Lynn Baxter Hospital Director Catherine.eaves@swyt. nhs.uk Sara.henley@behmht.nhs.uk Shirley.wakefield@ntw. nhs.uk yvonne.rutherford@ntw.nhs.uk Anouschka.Marwick@nt w.nhs.uk Jan.morris@bsmhft.nhs.uk shona.little@sept.nhs.u k luke.birmingham@sout hernhealth.nhs.uk Nick.Clark@sussexpart nership.nhs.uk vhitch@standrew.co.uk lbaxter@standrew.co.u k 96

97 Service Name Achievement Contact Name Contact Number Contact St Andrew's Healthcare Northampton - Women's Service St Mary s Hospital The Spinney Thornford Park Hospital Tony Hillis Wing Wood House Wood Lea Clinic The service has a central Health and Safety team and they report SUIs on the Datix system. Themes are mapped and lessons are learnt via action plans. There is also charity wide learning which is sent to other services. The service has employed a dedicated Family and Friends Representative who attends Clinical Governance meetings to help review and develop the service. Fire alarms and medical emergency tests take place monthly. Staff at Thornford Park attend learning and information sharing events with other hospitals in the region and NHS England. Desktop and live exercises are run regularly with a full scale evacuation of the unit recently run. The fire brigade are involved in the additional emergency planning forums. Lessons learnt are shared with members of staff at Wood House via the PRISM. There is a Datix system in place to monitor incident reporting. Root cause analysis training is also offered for staff to monitor trends. Dr Samudra Sarkar Consultant Psychiatrist Christine Walker Deputy Hospital Manager Rena Henderson Lead Occupational Therapist Paul O Connor Regional Hospital Director Copy in Dawn Jeffries Dawn Harwood Head of Service Simon Reed Hospital Manager Shona Little Integrated Clinical Lead Ssarkar@standrew.co.u k christinewalker@stgeor gehealthcaregroup.co.u k rena.henderson@partn ershipsincare.co.uk pauloconnor@priorygro up.com DawnJeffries@priorygro up.com Dawn.harwood@wlmht. nhs.uk Simon.reed@lighthouse -healthcare.co.uk shona.little@sept.nhs.u k 97

98 Service Name Achievement Contact Name Contact Number Contact Equalities Team Name Achievement Contact Name Contact Number Contact Alpha Hospital Bury Alpha Hospital Sheffield Alpha Hospital Woking Ash Ward Bracton Centre Bradley Woodlands Brooklands Hospital West Drive Cedar House Cheswold Park Hospital Chichester Centre The service has access to spiritual leaders who are able to communicate with deaf patients. Patients are provided with a copy of the Patient s Charter. The service sends service development surveys to the family and friends of patients. Patients are able to meet the advocate on the ward every Wednesday. The number for the advocate is up on the board in the ward. There is an extended hours telephone support service accessible to family and friends. The support line is available at evenings and weekends. Fun days, wellbeing days and coffee mornings are held at the service for the family and friends of patients. Family and friends are involved during the preadmission stage and there is a collaborative process towards service developments. The family and carer group meets regularly and is well attended. Sessions are themed based, focussing on topical issues or changes in legislation. Patients are involved in recruiting new staff and they represent the patient group at particular meetings. The service provides family and friends unable to visit with webcams in order for them to remain in regular contact with patients. Gender specific groups are provided at the service. Charlotte Garvey Head of Care Julie Donovan Hospital Director Sam Antwi-Marful Hospital Director Colin Reynolds Ward Manager Lisa Dakin Inpatient Service Manager & Head or Nursing Kath Dye Hospital Manager Lesley Wilson Matron Lynne Kirwan Operational Support Manager Emma Harrison Hospital Manager David Williams Director of Nursing Nick Badoorally Matron charlotte.garvey@alpha hospitals.co.uk Julie.Donovan@alphaho spitals.co.uk Sam.Antwi- Marful@alphahospitals. co.uk colin.reynolds@sompar.nhs.uk Lisa.dakin@oxleas.nhs. uk Kath.dye@lighthousehealthcare.co.uk Lesley.wilson@covwark pt.nhs.uk lynne.kirwan@calderso nes.nhs.uk emma.harrison@hunter combe.com dwilliams@cheswoldpar khospital.co.uk Nick.badoorally@susse xpartnership.nhs.uk 98

99 Service Name Achievement Contact Name Contact Number Contact Clifton House Cygnet Hospital Beckton Cygnet Hospital Blackheath Cygnet Hospital Stevenage Patients felt staff are respectful towards them and community meetings are held to gain the views of patients. Patient feedback is listened to and reported on via you said, we did boards. Patients are very involved in service development, for example, collaborative risk assessment training, service decoration, input into how the ward is run and what groups are put on, and the recruitment of staff. Female patients are provided with gender specific groups as well as activities with the male ward. Mark Dodd Matron & Mike Waldie Ward Manager Judith Etheridge Hospital Manager Sharon Fox Clinical Manager Joe Thomas Interim Hospital Manager health.co.uk h.co.uk ealth.co.uk Bowness Unit Patient audits have been performed to look at how long carers have to wait in reception before their visit. Rachel Green Deputy Head of Operations Francis Willis Wickham Unit George MacKenzie House Gerry Simon Clinic Guild Lodge Patients feel respected by staff. One patient stating It s like one big family. Staff spend more time here than at home'. There are established links with local Rethink and Bristol MIND charity for family & friends to access if needed. Activities are offered both as single gender and mixed gender. The service has introduced a patients newsletter which is sent to family and friends. They have a carer s forum and give questionnaires to family and friends. Patients are able to cook for their families and the service helps to facilitate and provide for this. Patients also praised the new menus at the service. Jocelyne White Ward Manager Julie Somerville Lead Occupational Therapist Wendy Scott-Earl Service Manager, Specialist Services Dr Joseph Vella Consultant Psychiatrist Lee Drake Integrated Clinical Manager jocelyne.white@lpft.nhs.uk julie.somerville@nhs.ne t Wendy.scottearl@cpft.nhs.uk joe.vella@bcpft.nhs.uk Lee.drake@lancashirec are.nhs.uk 99

100 Service Name Achievement Contact Name Contact Number Contact Ellesmere House Hazelwood House Hellesdon Hollins Park Hospital Wolfston House Lee Mill Unit Llanarth Court Hospital Morris Ward Newsam Centre Oxford Clinic Rathbone Low Secure Unit The service is working to update their website to include a virtual tour of the unit to allow family and friends to see the environment inside. Complaints that require an investigation are done so by an allocated investigator. All investigators are members of senior management and trained in Root Cause Analysis. There is a member of staff training in Systemic Family Therapy who can produce referral letters for interventions for family members. Patients are involved in interviewing new members of staff. The service offers family and friends orientation visits where they can visit the service and meet the team. The service offers a weekly allowance of per week if patients want to self-cater. The service provides access to a complaints officer who comes onto the ward and listens to patients complaints. This is implemented into feedback for patients through a flowchart which displays themes. The service is able to offer support session to families/carers with a psycho educational focus. Key workers also offer support through regular communication and updates on loved ones. The service is able to offer couples therapy and family therapy to carers, with follow up sessions if required. The service can also signpost family and friends to other services. PALS and the safeguarding department attend the clinical meetings on a monthly basis. Patients can access the Chief Executive of the Trust via the Tell Joe process. Dr Jayanth Srinivas Clinical Director & Julie Robbie PA Palmer Chinosengwa Registered Manager Brian Davis Deputy Service Manager Sue Lee Modern Matron - Secure Services Deborah Bull Deputy Head of Service Jane Quigley Ward Manager Dr Phil Huckle Regional Executive and Clinical Director Kristoff Bonello Clinical Lead Psychologist Kirstin Gillatt Ward Manager Dr Jude Deacon Head of Low Secure Forensic Service Sara Finlayson Head of Psychological Services jayanth.srinivas@sssft. nhs.uk julie.robbie@nhs.net Palmer.chinosengwa@p artnershipsincare.co.uk Brian.davis@nsft.nhs.u k Sue.lee@5bp.nhs.uk Debbie.Bull@eastlondo n.nhs.uk janequigley@nhs.net ext Phil.huckle@partnershi psincare.co.uk kristoff.bonello@nelft.n hs.uk Kirstin.gillatt@nhs.net Jude.deacon@oxfordhe alth.nhs.uk sara.finlayson@mersey care.nhs.uk 100

101 Service Name Achievement Contact Name Contact Number Contact Ridgeway River House Saddlebridge Recovery Centre & Alderley Unit Shaftesbury Clinic Southfield Low Secure Unit St Andrew's Healthcare Northampton - Women's Service St Andrew's Healthcare Nottinghamshire St John s House LDS The Orchard Tony Hillis Wing Wells Road Centre Patients can mix with patients from other wards, including female patients, at the Hub, at social events and during timetabled activities. Patients have access to gender specific as well as mixed-gender access to therapeutic and recreational activities. Patients, family and friends were consulted about the design of the new Alderley unit & members of the local community were invited to view this prior to opening. Patients use the feedback computer system on the ward where they can request changes to be made to the service. The patients reported that they also do mixed gender activities such as football. The Voice Ability advocacy service has links with carers and is available to contact. Patient representatives also attend 'our voice' meetings. Patients reported that they felt respected by staff and that staff make time for them if they are worried or upset. Patients are allowed to use the health and beauty facilities and do knitting and sewing on site. They also have the opportunity to go to the cinema, museum and Kew Gardens. Staff have adopted an if they don t come to us, we will go to them strategy in the hope to increase family and friends engagement. The service works with patients to educate them about governance systems, including what to expect when a complaint is made. Steve Godwin Deputy Head of Forensic Services Mental Health Ellie Bateman Service Director Dave Jones Clinical Service Manager Kirsty Murray Interim Operational Manager Dr Luke Birmingham Consultant Forensic Psychiatrist Dr Samudra Sarkar Consultant Psychiatrist Lisa Powell Hospital Director Fungai Nhiwatiwa Unit Manager Doreen Whande Senior Nurse Dawn Harwood Head of Service Lorraine Lockley Modern Matron stephen.godwin@nhs.n et Eleanor.Bateman@slam.nhs.uk david.jones@cwp.nhs.u k Kirsty.murray@swlstgtr.nhs.uk luke.birmingham@sout hernhealth.nhs.uk Ssarkar@standrew.co.u k lpowell1@standrew.co. uk fungai.nhiwatiwa@part nershipsincare.co.uk doreen.whande@wlmht.nhs.uk Dawn.harwood@wlmht. nhs.uk lorraine.lockley@nottsh c.nhs.uk 101

102 Service Name Achievement Contact Name Contact Number Contact Woodlands House Due to the mixed-gendered ward, the service is able to offer mixed-gendered activities which encourage patients to interact in a way that is similar to the community. Preeteema Gungah Ward Manager Preeteema.gungah@oxf ordhealth.nhs.uk 102

103 APPENDIX D: THE REVIEW PROCESS The overall benefit of being a member of the Quality Network for Forensic Mental Health Services is in taking part in the self and peer-reviews. The purpose of carrying out a selfreview and peer review process is to aim to improve services by applying and measuring services against standards, using the principles of the annual review Cycle, outlined in Figure 18 below. Figure 18: The Annual Review Cycle Agree standards Annual Forum and Report Action Planning ANNUAL REVIEW CYCLE Local Reports Compiled Self Reviews External Peer Review Self-review Each year the Quality Network organises a self-review for each unit. This involves units measuring themselves against standards for low secure care through the completion of a workbook. The Quality Network s Patient Reviewers facilitated telephone conferences supported by a member of the Quality Network s central team, to enable patient input at this stage of the review process. This is also repeated by the Quality Network s pool of Family and Friends Representatives who gain feedback from carers of member services. Peer-review visit The Quality Network organises a peer-review team to visit each low secure unit whose purpose is to validate the self-review scores and comments. The peer-review teams usually consist of four members of staff from two different services, usually including a Consultant Psychiatrist. Visits to other services Throughout the cycle, staff from each low secure unit participate in a peer-review visit to two other services as members of peer-review teams. Overall staff fed back that they find peer-review visits very useful, with some commenting that they are a great opportunity to acknowledge positives and enable staff to come together and share best practice. 103

104 Detailed local report Following the peer-review visit the Quality Network team writes a detailed local report for each member service. This report summarises the findings of the self-and peer-review, providing suggested action points made by the peer-review team for partly met and unmet criteria. The local report also generates and highlights key achievements for the service, as well as areas of improvement. Annual Members Forum Members are invited to an annual conference which provides member services with an overview of the last Cycle s findings, areas of focus and initiatives moving forward. Typically, presentations are given by the Project Team, Patient Reviewers, Family and Friends Representatives, as well as external attendees presenting on relevant topics from the Cycle. For example, at the 2015 LSU Annual Forum, presentations were given by the Scottish Forensic Network and the CQC. The Forum is also a great opportunity to invite member services to explore their experience of the review process, share achievements and discuss solutions for the challenges identified. Quality Network newsletter and discussion group The members newsletter provides policy news, project updates, articles written by members describing good practice initiatives and research taking place, as well as a regular column from the Quality Network s Patient Reviewers and Family and Friends Representative. Each newsletter has a theme to enable focused and relevant dissemination of information to our member services. Equally, the discussion group provides an opportunity to share real time queries and information and to access the experience and knowledge of other members. From Cycle 4 Policies shared on the discussion group are made available in an electronic library on the Quality Network s website 7. Lead reviewer training The Quality Network organises Lead Reviewer Training days which aim to train staff in the required skills for leading peer-review visits. These training days are an opportunity to familiarise members with the purpose of review visits and outline how a visit is structured and what to expect from host services as well as being part of a peer-review team. Similarly to all other events run by the Quality Network, attendees at Lead Reviewer Training events are encouraged to network and take part in exercises to promote sharing and support review environments

105 APPENDIX E: PROJECT TEAM Quazi Haque Chair, Advisory Group Paul Gilluley Chair, Advisory Group (until February 2015) Renata Souza Programme Manager Sarah Tucker Programme Manager (until December 2014) Sam Holder Deputy Programme Manager Geraldine Murphy Deputy Programme Manager, Medium Secure Services (until December 2014) Megan Georgiou Project Worker, Low Secure Services Amy Lawson Project Worker, Low Secure Services Francesca Coll Project Worker, Low Secure Services Emily Lesnik Project Worker, Medium Secure Services Tiffany Rafferty Project Worker, Medium Secure Services 105

106 APPENDIX F: ADVISORY GROUP Dan Beales Consultant Forensic Psychiatrist, Fromeside, Avon and Wiltshire Partnership NHS Foundation Trust Margaret Britton Family & Friends Representative, Quality Network for Forensic Mental Health Services Nikki Churchley Mental Health and Programme of Care Lead, South of England South West Team, NHS England Sheryle Cleave Senior Clinical Nurse, Northumberland Tyne and Wear NHS Foundation Trust Lisa Dakin Inpatient Service Manager and Head of Nursing, Royal College of Nursing Louise Davies Mental Health and Programme of Care Lead, Yorkshire & Humber Team, NHS England Jude Deacon Head of Forensic Mental Health and Prison Healthcare Services, Oxford Health NHS Foundation Trust John Enser Director of Bexley Mental Health Services and Director of Forensic Prison Services, Royal College of Nursing Colleen Fahy Nurse Consultant, Alpha Hospitals Bury Tom Fahy Consultant Psychiatrist, Chair of Forensic Faculty, Royal College of Psychiatrists Julian Haines Social Work Manager, North London Forensic Services/National Group for Social Work Managers in Secure Services Quazi Haque Consultant Forensic Psychiatrist and Group Medical Director, Partnerships in Care Michael Humes Patient Reviewer, Quality Network for Forensic Mental Health Services Dawn Jeffries Director of Clinical Services, Thornford Park Hospital, Priory Group Harry Kennedy Executive Clinical Director and Consultant Forensic Psychiatrist, National Forensic Mental Health Service, Central Mental Hospital Jeremy Kenney-Herbert Clinical Director and Consultant Forensic Psychiatrist, Reaside Clinic 106

107 Mat Kinton Mental Health Act Policy Advisor, Care Quality Commission Gail McCabe Family and Friends Representative, Quality Network for Forensic Mental Health Services Seb Pringle Patient Reviewer, Quality Network for Forensic Mental Health Services Huw Stone Consultant Forensic Psychiatrist, Surrey Community Forensic Mental Health Service, Surrey and Borders Partnership NHS Foundation Trust To join the elsu discussion group please Join to The Low Secure Network will be developing a web based member resources during the next Cycle. If you would like to contribute please forward your policies to lsu@rcpsych.ac.uk. The member resources will be a password protected page. Access details will be sent out to all member services. 107

108 APPENDIX G: QNFMHS PATIENT REVIEWERS Abdirisak Hussein Alan Taylor Hannah Moore Helen Slater Ian Callaghan Michael Humes Roger Sharp Sarah Markham Seb Pringle Suzanne Harrison Tania Charles APPENDIX H: QNFMHS FAMILY & FRIENDS REPRESENTATIVES Clari East George Cooley Gail McCabe Margaret Britton Maureen Clare Susan Riding CI 108

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