Ayrshire & Arran Primary Care NHS Trust. Local Report ~ June Schizophrenia

Ayrshire & Arran Primary Care NHS Trust Local Report ~ June 2004 Schizophrenia

NHSScotland Regional Breakdown 13 12 15 1 Argyll & Clyde 2 Ayrshire & Arran 3 Borders 9 7 4 Dumfries & Galloway 5 Fife 6 Forth Valley 7 Grampian 1 6 14 5 8 Greater Glasgow 9 Highland 10 Lanarkshire 11 Lothian 8 2 10 16 11 3 12 Orkney 13 Shetland 14 Tayside 15 Western Isles 4 16 The State Hospitals Board for Scotland

Local Report ~ June 2004 Schizophrenia Schizophrenia is a serious and common mental illness. The lifetime risk of developing the illness is about 1 in 100. Many people who have the illness will continue to experience symptoms of varying degree for many years and will require help and support from a number of different services. Providing services for people with schizophrenia is an important and significant part of the work undertaken by the mental health service in Scotland. The Mental Health Project Group developed standards which reflect the journey of care experienced by individuals with a diagnosis of schizophrenia and those who care for them. The 11 standards developed, which reflect the provision of healthcare in both hospital and community settings, were published in January 2001. Six of these 11 standards were reviewed in 2001. This report presents the findings from the NHS Quality Improvement Scotland (NHS QIS) peer review of performance against the remaining five standards.

NHS Quality Improvement Scotland 2004 ISBN 1-84404-264-2 First published June 2004 NHS Quality Improvement Scotland (NHS QIS) consents to the photocopying, electronic reproduction by uploading or downloading from the website, retransmission, or other copying of the findings contained in this report, for the purpose of implementation in NHSScotland and educational and not-for-profit purposes. No reproduction by or for commercial organisations is permitted without the express written permission of NHS QIS. Copies of this report, the Clinical Standards for Schizophrenia, and other documents produced by NHS QIS, are available in print format and on the website. www.nhshealthquality.org

Contents Contents 1. Setting the Scene 5 1.1 How the Standards were Developed 6 1.2 How the Review Process Works 6 1.3 Reports 9 2. Summary of Findings 11 2.1 Overview of Local Service Provision 11 2.2 Phase 1 Update 13 2.3 Phase 2 Review 16 2.3.1 Self-Assessment Methodology 16 2.3.2 Summary of Findings Against the Standards 17 3. Detailed Findings Against the Standards 22 Appendix 1 Glossary of Abbreviations 36 Appendix 2 Review Team Members 37 Appendix 3 Mental Health (Schizophrenia) Project Group Members 38 Appendix 4 Timetable of Review Visits 41 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 3

1 Setting the Scene 1. Setting the Scene NHS Quality Improvement Scotland (NHS QIS) was set up by the Scottish Parliament in 2003 to take the lead in improving the quality of care and treatment delivered by NHSScotland. The purpose of NHS QIS is to improve the quality of healthcare in Scotland by setting standards and monitoring performance, and by providing NHSScotland with advice, guidance and support on effective clinical practice and service improvements. About this Report The Clinical Standards for Schizophrenia were published in January 2001. These standards are being used to assess the quality of services provided by NHSScotland nationwide, in both community (including primary care) and hospital settings. The peer review of these standards was conducted in two phases. Phase 1 consisted of the review of performance against six of the 11 clinical standards for schizophrenia. A national overview of performance in relation to the six standards was published in March 2002. Local reports, presenting the findings from each organisation reviewed, were also published. This report presents the findings from the Phase 2 peer review of Ayrshire & Arran Primary Care NHS Trust 1 and details performance against the remaining five standards. It also contains an update summary of progress against the six standards reviewed in Phase 1. This review visit took place on 5 November 2003, and details of the visit, including membership of the review team, can be found in Appendix 2. 1. References to Trusts in this report reflect the NHSScotland organisational structure at the time of the review visit. NHS Trusts were abolished on 1 April 2004. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 5

1. Setting the Scene 1.1 How the Standards were Developed In November 1999, a Mental Health (Schizophrenia) Project Group was established, under the chairmanship of Dr Sandra Grant OBE, Chief Executive, Scottish Health Advisory Service (SHAS - now merged into NHS QIS). Membership of the Group included both healthcare professionals and members of the public. The remit of the Group was to oversee the quality assurance process of: developing standards; reviewing performance against the standards throughout Scotland, using self-assessment and external peer review; and reporting the findings from the review. When developing the schizophrenia standards, a Scotland-wide consultation process was undertaken. The views of health service staff, service users, carers and the public were sought, and all the relevant evidence available at the time was taken into account. Draft standards were also piloted in three Primary Care NHS Trusts: Dumfries & Galloway, Greater Glasgow and Highland. The research and development directorate at Greater Glasgow Primary Care NHS Trust was commissioned to establish the evidence base for the clinical standards for schizophrenia. The evidence base document produced was published and issued to Trusts in January 2001. In addition to being underpinned by the best evidence available, the standards were influenced by the views of service users, carers, professionals and the public. Following publication of the standards, the Mental Health (Schizophrenia) Project Group was reconstituted under the chairmanship of Dr Linda Watt, Divisional Medical Director for Mental Health and Learning Disabilities, Greater Glasgow Primary Care NHS Trust (see Appendix 3). The remit of the reconstituted Mental Health (Schizophrenia) Project Group was to oversee the roll-out of the Phase 2 review process throughout Scotland, and the reporting of findings. 1.2 How the Review Process Works The review process has two key parts: local self-assessment followed by external peer review. First, each NHS Board assesses its own 6 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

performance against the standards. An external peer review team then further assesses performance, both by considering the self-assessment data and visiting the NHS Board to validate this information and discuss related issues. The review process is described in more detail below (see also the flow chart on page 10). Self-Assessment by NHS Boards On receiving the standards, each NHS Board assesses its own performance using a framework produced by NHS QIS. This framework includes guidance about the type of evidence (eg guidelines, audit reports) required to allow a proper assessment of performance against the standards to be made. The NHS Board submits the data it has collected for this selfassessment exercise to NHS QIS before the on-site visit, and it is this information that constitutes the main source of written evidence considered by the external peer review team. External Peer Review An external peer review team then visits and speaks with local stakeholders (eg staff, service users, carers) about the services provided. Review teams are multidisciplinary, and include both healthcare professionals and members of the public. All reviewers are trained. Each review team is led by an experienced reviewer, who is responsible for guiding the team in their work and ensuring that team members are in agreement about the assessment reached. The composition of each team varies, and members have no connection with the NHS Board they are reviewing. This promotes the sharing of good practice, and ensures that each review team assesses performance against the standards, rather than makes comparisons between results. At the start of the on-site visit, the review team meets key personnel responsible for the service under review. Reviewers then speak with local stakeholders about the services provided. After these meetings, the team assesses performance against the standards, based on the information gathered during both the self-assessment exercise and the on-site visit. The visit concludes with the team providing feedback on its findings to the NHS Board. This includes specific examples of local initiatives drawn to the attention of the review team (recognising that other such examples may exist), together with an indication of any particular challenges. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 7

1. Setting the Scene Assessment Categories Each review team assesses performance using the categories met, partially met, not met, and not met (insufficient evidence), as detailed below: Met applies where the evidence demonstrates the standard and/or criterion is being attained. Partially met applies where the evidence demonstrates that the standard and/or criterion is either being met in only some areas of the service, or only some components of the criterion are being met. Not met applies where the evidence demonstrates the standard and/or criterion is not being attained. Not met (insufficient evidence) applies where no evidence is available for the review team, or where the evidence available is insufficient to allow an assessment to be made. A final category not applicable is used where a standard and/or criterion does not apply to the NHS Board under review. 8 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

1.3 Reports After each review visit NHS QIS staff draft a local report detailing the findings of the review team. This draft report is sent to the review team for comment, and then to the NHS Board to check for factual accuracy. The local report is published only after all the visits for that topic have been undertaken nationwide. Once a national review cycle is completed, the relevant project group reconvenes to examine review findings and make recommendations. The project group then oversees the production of a national overview of service provision across Scotland in relation to the standards. This document includes both a summary of the findings (highlighting examples of local initiatives and challenges for the service) and recommendations for improvement. Part of the remit of NHS QIS is to report whether the services provided by NHSScotland, both nationally and locally, meet the agreed standards. This does not include reviewing the work of individual healthcare professionals. In achieving this aim, variations in practice (and potential quality) within a service will be encountered. In such cases, variations are reported. Please note - all reports published are available in print format and on the NHS QIS website. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 9

1. Setting the Scene The Review Process After Visit During Visit Prior to Visit Standards published and issued î Self-assessment framework finalised and issued NHS Board undertakes self-assessment exercise and submits outcomes to NHS Quality Improvement Scotland ê NHS Quality Improvement Scotland sends information from self-assessment submission to peer review team ê Two-way presentations covering background on NHS Quality Improvement Scotland and local service provision Draft local report produced and sent to review team for comment í Review team meets stakeholders to discuss local services Review team assesses performance in relation to the standards Review team feeds back findings to NHS Board ê ê Draft local report sent to NHS Board to check for factual accuracy ê Project Group considers findings of local reviews and drafts national overview ê NATIONAL OVERVIEW AND LOCAL REPORTS PUBLISHED 10 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

2 Summary of Findings 2. Summary of Findings 2.1 Overview of Local Service Provision Ayrshire & Arran is situated in south-west Scotland and has a population of around 367,060. The majority of the population live in urban areas, of which Ayr and Kilmarnock are the largest in the region, although a significant proportion live in rural areas. The proportion of older people in the population is higher than the national average, as are levels of illness and deprivation. Local NHS System and Services Ayrshire & Arran NHS Board is responsible for improving the health of the local population and for the delivery of the healthcare required. It provides strategic leadership and has overall responsibility for the efficient, effective and accountable performance of the NHS in Ayrshire & Arran. At the time of the review visit, the NHS Board area contained one Acute and one Primary Care Trust (Ayrshire & Arran Acute Hospitals NHS Trust and Ayrshire & Arran Primary Care NHS Trust), which together provided its clinical services. Both the Board and the Trusts were accountable for the services provided, through the framework of clinical governance. Further information about the local NHS system can be accessed via the website of NHS Ayrshire & Arran: www.show.scot.nhs.uk/aahb Ayrshire & Arran Primary Care NHS Trust was established in 1999 and delivers a range of primary care, learning disability and mental health services. Services for people with a diagnosis of schizophrenia are organised in three sectors: East Ayrshire, North Ayrshire, and South Ayrshire. The information presented in the following section relates to service provision for people with a diagnosis of schizophrenia and is taken from the scoping information submitted by the Trust prior to the peer review visit. Information on Population Trust catchment population (all ages) 375,000 Number of people (16-65 years) with a diagnosis of schizophrenia who - are currently cared for by the Trust 1,029 - attended a new patient appointment in the last 12 months 40 - were admitted in the last 12 months 175 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 11

2. Summary of Findings In-Patient Services Four acute admission wards: two wards each at Ailsa Hospital, Ayr, and Crosshouse Hospital, Kilmarnock. Intensive psychiatric care unit: Ailsa Hospital. In-patient dual diagnosis unit: Loudoun House, Ailsa Hospital. Continuing care/rehabilitation unit: Ailsa Hospital. Liaison psychiatry service: Ayr Hospital; Crosshouse Hospital, Kilmarnock. Community Services Six community mental health teams: Ayr (two teams); Cumnock; Irvine; Kilmarnock; Stevenston. Day Activities Team and Art Studio: Ailsa Hospital, Ayr. Day centre: Hartfield House, Ayr. Dual diagnosis day unit: Loudoun House, Ailsa Hospital. Compass Centre, Irvine. Three Towns Resource Centre, Stevenston. Community Forensic Team. Intensive Community Support Service. Service User and Carer Groups The Trust has links with a number of user and carer groups including: Ayr Action for Mental Health; Health in Mind (Clubhouse); Morven Centre; Panel of Reference; Princess Royal Trust for Carers; Richmond Fellowship Scotland Health; Scottish Association for Mental Health; a Carers Connection; and Inclusion Ayrshire. The Trust has a patients council: Voice Advocacy Project. Service user advocacy service: individual advocacy is provided in each of the local authorities areas. Carer advocacy service: in North Ayrshire the advocacy service is funded to provide a service for carers of people with mental health problems. Carers centres in all areas provide this function also. Local groups (Trust-a-Carers Connection and Panel of Reference) advocate on a wider sense, not on an individual level. 12 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

2.2 Phase 1 Update Performance against the Clinical Standards for Schizophrenia was reviewed in two phases. The first phase review at Ayrshire & Arran Primary Care NHS Trust, covering six of the standards 2, was undertaken in July 2001. As part of the second review phase the Trust was invited to provide an update report, summarising what it considered to be the key developments in relation to the six standards reviewed in Phase 1. These key developments are described in this section under seven headings: User Assessment and Involvement; Carer Assessment and Involvement; Documentation; Guidelines; Audit; Service Provision; and Training. These headings reflect the main themes running through the six standards in question, which were highlighted in local reports and the national overview published in March 2002. This section is not an exhaustive update on all the criteria/issues from the first phase instead, key developments in relation to Standards 2 and 7-11 are summarised on the following pages. It is acknowledged that further developments may also have been made. If a heading is not covered here, it is assumed that performance in this area has not changed significantly since the first review phase. It should be noted that this summary is based solely on information provided by the Trust and has not been verified by peer review. However, there was a discussion session during the review visit where the Trust presented on its progress. The Ayrshire & Arran Primary Care NHS Trust local report and national overview from the first phase provide a context for this progress update. Copies of the national overview and the local report containing full details of the Trust s performance against the standards reviewed in Phase 1 are available in print format and on the NHS Quality Improvement Scotland (NHS QIS) website (www.nhshealthquality.org). 2. The six standards covered by the first review phase were: Standard 2 (Initial Diagnosis); Standard 7 (Information and Support for Carers); Standards 8 & 9 (Prescribing Antipsychotic Drugs); Standard 10 (Social and Psychological Approaches to Care); and Standard 11 (Misuse of Alcohol and Illicit Drugs). Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 13

2. Summary of Findings Much of the progress made within Ayrshire & Arran Primary Care NHS Trust has been through the introduction of its integrated care pathway (ICP). The ICP was implemented following a successful bid to the Mental Health and Wellbeing Development Fund. The ICP continues to be rolled out throughout the Trust area. User Assessment and Involvement An information booklet explaining the ICP and its relevance to their situation has been produced for service users and carers. A directory of local services for users and carers has been developed and is available for reference. Carer Assessment and Involvement The introduction of the ICP, which includes the use of Functional Assessment of Clinical Environment (FACE) software, contains a section on assessing the needs of carers, which is completed before each review. A group of carers and staff have been meeting to look at information needs. This group has agreed on relevant pieces of information which have subsequently been distributed to clinical areas. Documentation A Psychological Therapies for Psychosis Record of Identified Needs (PSYRIN) proforma has been developed. This form identifies criteria, where psychological therapies for service users and carers are indicated. This form will be used routinely at initial assessment and reviews to allow prioritisation and allocation of referrals. This form is currently being used in a Trust-wide audit of need for psychological therapies. A life skills checklist has been developed, which highlights needs which require to be addressed. A medication review sheet has been produced, which details all drugs prescribed and provides an up-to-date medication history. A first contact sheet (medication) has been developed. 14 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

Guidelines The Trust produced a drug and alcohol policy in January 2003. This policy has been developed to protect the safety of patients, visitors, and staff. Guidelines and a monitoring sheet for the use of high-dose antipsychotic medication have been developed. Training An ongoing training programme explaining the side-effects associated with anti-psychotic drugs, conducted by the pharmacy advisor and the ICP team, is available. Training in the use of Liverpool University Neuroleptic Side Effects Rating Scale (LUNSERS) for all staff using the ICP has commenced. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 15

2. Summary of Findings 2.3 Phase 2 Review 2.3.1 Self-Assessment Methodology This section provides an overview of the Trust s approach to the selfassessment exercise. Details of the methodology the Trust employed in order to complete the five self-assessment questionnaires are given below: Mental Health Service Questionnaire: As requested, 1 questionnaire was completed on behalf of the Trust. Multidisciplinary Mental Health Team Questionnaire: Six multidisciplinary mental health teams and two continuing care areas completed questionnaires. The two continuing care areas completed the questionnaire in order to highlight changes in practice evident in these areas in terms of overall care. In total, 8 questionnaires were completed out of 8 issued. General Practice Questionnaire: In total, 31 questionnaires were completed. Service User Questionnaire: Users and carers were invited to take part in the process and were supported in completing the questionnaires by keyworkers. In total, 19 questionnaires were completed. Carer Questionnaire: In total, 10 questionnaires were completed. 16 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

2.3.2 Summary of Findings Against the Standards A summary of the findings from the review, including examples of local initiatives drawn to the attention of the review team, is presented in this section. A detailed description of performance against the standards/ criteria is included in Section 3. Ayrshire & Arran Primary Care NHS Trust is making progress in a number of areas in the service which it provides for people who have a diagnosis of schizophrenia. The Trust has introduced an integrated care pathway (ICP) following funding from the Mental Health and Wellbeing Development Fund. An ICP is a system that facilitates multi-agency care and treatment for a specific service user group, based on guidelines and relevant research documents. The ICP is being implemented on a phased basis across the three local authority areas North, East and then South Ayrshire. The ICP and electronic software to support this have now been introduced into the community setting in North and East Ayrshire. The implementation of the ICP in South Ayrshire is to begin shortly. The review team was impressed by the work to date, and by the continued commitment and enthusiasm of all staff working throughout the service during this new process. Information on Populations and Individuals At the time of the visit, the Trust did record, in two out of the three geographical areas (North and East Ayrshire), the number of individuals in the local population who have a diagnosis of schizophrenia. The record states which needs are and are not being met. The review team commended the existence of a severe mental illness register in North and East Ayrshire, and noted that incorporating this into the ICP would allow for an improved recording mechanism. General practices in two out of the three geographical areas record the number of people registered with the practice who have a diagnosis of schizophrenia. Those that do record this diagnosis reported that the record does state the needs of the individual. The record is updated with the multidisciplinary mental health team at least once per year. The joint ownership of records in North and East Ayrshire ensures good communication between all parties involved in caring for the service user. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 17

2. Summary of Findings Example of local initiative Primary care collaboration with mental health teams has resulted in GP practices in North and East Ayrshire having a register of people with severe long-term mental health problems. A number of practices also have shared anonymised data which allows planning of services and comparison of numbers. This information is held at practice level and is updated jointly with mental health teams. The Trust reported that all GPs use computerised record systems and that in East Ayrshire, where GPs use the General Practice Administration System for Scotland (GPASS), there is a specific patient management screen. Initial Assessment and Care Planning The Trust does not have a guideline in place for ensuring that an appropriate multidisciplinary needs and risk assessment is undertaken. A flow chart, however, is in use and available to staff in each of the clinical areas. Consultant psychiatrists, GPs, carers and nursing staff are always involved in the initial needs and risk assessment. However, input from psychologists and pharmacists is limited. The review team noted that equitable access to a full multidisciplinary team is not possible, due to issues with access to pharmacy and psychological services. The use of the Psychological Therapies for Psychosis Record of Identified Needs (PSYRIN) proforma in the initial needs and risk assessment has resulted in a fuller assessment for both the service user and carer. A plan of care is developed when a person is diagnosed with schizophrenia, and the person is involved in the development of the plan. However, a copy of the plan is rarely given to all those named in it. Standardised methods are used to document the initial needs and risk assessment procedure and the initial plan of care. 18 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

Example of a local initiative An integrated care pathway (ICP) was introduced following funding from the Mental Health and Wellbeing Development Fund. The ICP is being implemented on a phased basis across the three local authority areas North, East and then South Ayrshire. Electronic software to support the ICP has now been introduced into the community setting in North and East Ayrshire. The implementation of the ICP in South Ayrshire is to begin shortly. The review team noted the commitment shown towards the ICP by staff, and encouraged the continued roll-out of the ICP. Ongoing Assessment and Care Planning All persons with a diagnosis of schizophrenia have a named consultant psychiatrist. However, not all service users whose care is being shared by their GP and the specialist mental health services have an annual review. The Trust has conducted an audit of service users only known to their GP to ensure that everyone is offered a yearly review. The review team noted this was an encouraging first step which could be used as a basis for extending links with all areas of primary care. Example of a local initiative GPs are sent a comment form before a review, which they are asked to complete and return in advance if they are unable to attend, in order that their comments are part of the review session. Not all persons with a diagnosis of schizophrenia have a care plan developed with them, which is recorded in their casenotes and distributed to all those named in the plan. In addition, the plan of care does not detail the person s drug treatment, and the roles and responsibilities of all involved in caring for the person. The review team noted that the extension of carer involvement into ongoing care planning would assist in strengthening the support the Trust provides for carers. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 19

2. Summary of Findings Example of a local initiative A positive support break flat situated in North Ayrshire is available to service users and carers throughout the Trust area for respite purposes. The flat is owned by the local authority and managed by the local community mental health teams. The Trust does audit user and carer satisfaction with care arrangements. The audit, however, does not take place across the Trust. Transferring Care Admission to Hospital When a person is admitted to hospital on either an informal or compulsory basis, the Trust does not have guidelines for staff to follow. It does, however, have a nursing admission procedure, which nursing staff use. On admission to hospital, individuals are given an appropriate assessment and examination. This assessment currently does not include assessing the needs of carers. An in-patient plan of care is developed on admission to hospital, based on the outcomes of the needs and risk assessment. This plan is documented in the casenotes. Information is available from existing plans of care in the community. The review team commended the effective links with community staff, and noted that these could be further enhanced by the introduction of the ICP into in-patient areas. While the person is in hospital, the plan of care is routinely reviewed and each individual has one nurse identified as being responsible for their care. All individuals caring for the person are invited to the review. In addition, community staff attend these reviews to assist with early discharge planning. In-patients receive a variety of information when they are admitted to hospital. An ICP information booklet has been produced by the Trust for service users and carers and this was commended by the review team. Staff inform in-patients of their right to appoint an independent advocate and are provided with information on how they can access the service. Strong links with advocacy services were demonstrated. Advocates visit in-patient wards at Crosshouse Hospital, Kilmarnock, and Ailsa Hospital, Ayr, for group advocacy sessions once per week. One-to-one sessions can also be arranged. 20 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

Transferring Care Discharge from Hospital The Trust has guidelines detailing the procedure to be followed when planning the discharge from hospital of a person with a diagnosis of schizophrenia. It was noted by the review team that the Trust may wish to consider updating the guidelines in light of the ICP development. The guidelines also contain information regarding rapid self-discharge and medication, which provides step-by-step guidance for staff who may find themselves faced with these situations. The review team commended the wide involvement in discharge planning of all staff caring for the service user, both in hospital and in the community. Example of a local initiative Discharge facilitators work in in-patient wards at Crosshouse Hospital, Kilmarnock, and Ailsa Hospital, Ayr, to assist nursing staff with organising complex discharge cases. The facilitators co-ordinate and liaise with a variety of individuals regarding a person s discharge, allowing a smooth transfer of care. On discharge, a plan of care is developed with the service user, based on the needs and risk assessment at the time of discharge. The plan is documented in the casenotes. However, a copy is not given to all those named in the plan. Procedures to be followed in the event of a crisis or emergency are not included in the plan. When a person is being discharged from hospital, staff routinely consider the need for the service user to be included on the Care Programme Approach (CPA). The Trust does not audit the use of the CPA, however, a pilot is currently taking place. Example of a local initiative A discharge co-ordinator works with one consultant team, meeting with patients on the ward before discharge, and then following them up in their own homes for up to 8 weeks after discharge. This scheme allows patients to have one person who they can contact for support and advice, before, at and after discharge. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 21

3. Detailed Findings Against the Standards Standard 1: Information on Populations and Individuals Standard Statement The number of people in a local population who have a diagnosis of schizophrenia is recorded, together with their needs, both met and unmet. Ayrshire & Arran Primary Care NHS Trust Essential Criteria 1: The Trust records the number of people in the local population who have a diagnosis of schizophrenia, together with the needs of this group of people and whether these needs currently are or are not being met. STATUS: Partially met The Trust records the number of people with a diagnosis of schizophrenia in two out of the three geographical areas. The record states which needs are and are not being met. The Trust reported that it has a severe mental illness register in North and East Ayrshire. 2: Each general practice records: a) the number of people registered with the practice who have a diagnosis of schizophrenia or for whom this diagnosis is being considered; together with b) the needs of each individual and whether these needs currently are or are not being met.the general practice and the local specialist mental health service have joint responsibility for ensuring that this information is updated at least once per year. STATUS: Partially met General practices in two out of the three geographical areas record the number of people registered with the practice who have a diagnosis of schizophrenia or for whom this diagnosis is being considered. In addition, met and unmet needs are recorded, and the record is updated with the multidisciplinary mental health team at least once per year. In East Ayrshire, within the General Practice Administration System for Scotland (GPASS), there is a patient management screen for the recording of this information. 22 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

3: The reasons for the recording of this information by the person s general practice are discussed with the person. STATUS: Not met Staff interviewed on the day of the visit reported that the reasons for the recording of this information by the person s GP are discussed with the person. Service users and carers reported that this does not happen. In addition, GPs indicated in their self-assessment that they rarely discuss this with service users. Desirable Criteria 4: This information recorded by the general practice is computerised. STATUS: Partially met Of the GPs who indicated that they keep records, they all reported that the information they record is computerised. The GPs who keep records are in North and East Ayrshire, where the integrated care pathway (ICP) and electronic software are in use in the community. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 23

3. Detailed Findings Against the Standards Standard 3: Initial Assessment and Care Planning Standard Statement When a person is diagnosed with schizophrenia, a multidisciplinary assessment of their needs is made and a plan of care, based on the outcomes of this assessment, is established. This assessment determines the person s health needs (physical and psychological), social needs (recreational, occupational, housing), and their risk of self-neglect and harm to self and/or others. The particular need which the person and their carer will have, during the first year after diagnosis, for information about illness and the services/treatments available is also assessed. Ayrshire & Arran Primary Care NHS Trust Essential Criteria 1: There is a guideline detailing the procedure to be followed to ensure that an appropriate multidisciplinary needs and risk assessment is undertaken when a person is diagnosed with schizophrenia. STATUS: Not met The Trust does not have a guideline detailing the procedure to be followed to ensure that an appropriate multidisciplinary needs and risk assessment is undertaken when a person is diagnosed with schizophrenia. A flow chart, however, is in existence, which is available to staff in each of the clinical areas. 2: The involvement of the following people in this initial needs and risk assessment is considered and a record of those involved is documented in the casenotes: user, carer, consultant psychiatrist, general practitioner, nursing staff, occupational therapist, pharmacist, psychologist, social worker. STATUS: Partially met The multidisciplinary mental health team data indicated that consultant psychiatrists, GPs, carers and nursing staff are always involved. Occupational therapists and social workers are routinely involved. Input from psychologists and pharmacists is limited. In addition, GPs reported that they are rarely involved in the needs assessment. Information received from service users and carers indicated that they are not always involved. The review team noted that equitable access to a full multidisciplinary team was not posssible, due to issues with access to pharmacy and psychology services. 24 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

3: When a person is diagnosed with schizophrenia a plan of care is developed with them, based on the outcomes of this needs and risk assessment. This initial plan of care is documented in the casenotes and a copy is given to all those named in this plan of care. STATUS: Partially met Staff reported that when a person is diagnosed with schizophrenia a plan of care is routinely developed with them, based on the outcomes of the risk and needs assessment. The initial plan of care is documented in the casenotes. A copy of the plan, however, is rarely given to all those named in the plan. 4: This initial plan of care details: a) the needs of both the person and their carer, and whether these needs currently are or are not being met; b) the roles and responsibilities of all individuals and agencies involved in caring for the person; c) the identity of one individual responsible for coordinating the care; d) the person s drug treatment; e) the information the person and their carer will be offered throughout the first year after diagnosis; f) the identity of one individual responsible for ensuring this information is offered; g) the procedures to be followed in the event of a crisis or emergency; and h) the provision for respite care. STATUS: Partially met The review team agreed, after reviewing the documentation provided and meeting with staff on the day of the visit, that, with the exception of the person s drug treatment and the identity of one individual responsible for ensuring that information is offered, all of the other areas are detailed in the plan. 5: Throughout the first year after a person is diagnosed with schizophrenia their care arrangements are reviewed by a multidisciplinary mental health team, and a consultant psychiatrist reviews their care arrangements at least once every 3 months. STATUS: Met The review team was informed that a person with a diagnosis of schizophrenia has their care reviewed by a multidisciplinary mental health team and consultant psychiatrist at least once every 3 months. A prompt exists in the ICP to highlight when a review is required. For those service users not part of the ICP their keyworker highlights when a review is required. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 25

3. Detailed Findings Against the Standards Desirable Criteria 6: Standardised methods are used to document the initial needs and risk assessment procedure and the initial plan of care. STATUS: Met After discussion with staff and reviewing documentation, the review team agreed that standardised methods are used to document the initial needs and risk assessment procedure and the initial plan of care. The use of the psychological therapies for psychosis record of identified needs (PSYRIN) proforma in the initial needs and risk assessment has resulted in a fuller assessment for both the service user and carer. 7: Within every multidisciplinary mental health team are staff who have the necessary skills and knowledge to provide users and carers with appropriate information throughout the first year after diagnosis. STATUS: Met The review team was satisfied that staff possess the necessary skills and knowledge to provide users and carers with the appropriate information throughout the first year after diagnosis. Each multidisciplinary mental health team is comprised of registered community psychiatric nurses (CPNs) and a range of professionals from other disciplines. Staff receive training as part of their ICP training which gives them additional skills and knowledge to assist service users and carers. 26 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

Standard 4: Ongoing Assessment and Care Planning Standard Statement Every person who has a diagnosis of schizophrenia has access to services according to their needs. The care provided by these services is planned with the person, is well co-ordinated and reviewed regularly. Ayrshire & Arran Primary Care NHS Trust Essential Criteria 1: Every person who has a diagnosis of schizophrenia has a named consultant psychiatrist. If a person does not wish their general practitioner to share their care with a consultant psychiatrist and the specialist mental health services, and/or such shared care arrangements are no longer required, then this decision is recorded in the person s casenotes (general practice and mental health service) along with the rationale for this decision. This decision is reviewed with the person. STATUS: Partially met All persons with a diagnosis of schizophrenia have a named consultant psychiatrist. In addition, the review team was informed that if the person does not wish shared care, this information is recorded in the casenotes and is reviewed with the person. Following discussions with staff on the day of the visit, however, the review team noted that this information is not always recorded in the casenotes in each of the geographical areas. 2: Every person who has a diagnosis of schizophrenia and whose care is being shared by their general practitioner and the specialist mental health services has a multidisciplinary review of their care undertaken at least once a year. STATUS: Partially met Multidisciplinary mental health team and GP data indicated that service users whose care is being shared do not always have a review at least once a year. Following discussions with staff on the day of the visit, the review team also concluded that these reviews do not happen in each of the geographical areas. All GPs in the areas where reviews take place are sent an information sheet and asked to provide comments in advance of the meeting, if they are unable to attend. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 27

3. Detailed Findings Against the Standards The Trust has conducted an audit of service users only known to their GP to ensure that everyone is offered a yearly review. 3: This review includes an assessment of: a) the person s mental and physical health; b) their social care needs; c) their drug treatment; d) their risk of self-neglect and harm to self and/or others; e) their carer s needs; and f) their need to be included on the Care Programme Approach. The decision as to whether a person should or should not be included on the Care Programme Approach is recorded in the casenotes together with the rationale for this decision. STATUS: Partially met After reviewing the documentation, and following discussions with staff on the day of the visit, the review team agreed that the review does include an assessment of each of the areas listed. However, the review team concluded that reviews are not happening consistently throughout the Trust. 4: Every person who has a diagnosis of schizophrenia and whose care is being shared by their general practitioner and the specialist mental health services has an up-to-date plan of care developed with them, based on the outcomes of their most recent multidisciplinary review. This plan of care is documented in the casenotes and a copy is given to all those named in this plan of care. STATUS: Partially met A person with a diagnosis of schizophrenia routinely has a care plan, which is developed with them and is based on the outcomes of their most recent multidisciplinary review. The plan of care is documented in the casenotes. However, following discussions with staff on the day of the visit, the review team concluded that this does not happen across the whole Trust, and that a copy of the plan is not given to all those named in it. 5: This plan of care details: a) the needs which currently are and are not being met; b) the roles and responsibilities of all individuals and agencies involved in caring for the person; c) the identity of one individual responsible for co-ordinating the care; d) the person s drug treatment; e) the procedures to be followed in the event of a crisis or emergency; and f) the provision for respite care. STATUS: Partially met Following the review of documentation, and discussions with staff on the day of the visit, the review team was satisfied that the individual plan of care includes all of the areas detailed above, with the exception of the person s drug treatment, and the roles and responsibilities of all individuals and agencies involved in caring for the person. 28 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004

6: Multidisciplinary mental health teams, as an integral part of their work, provide a proactive model of care to meet the needs of those people who have difficulty in maintaining contact with services. STATUS: Partially met Data collected from the service indicated that all multidisciplinary mental health teams provide a proactive model of care as an integral part of their work. Staff interviewed on the day of the visit were able to discuss the work they do to meet the needs of those people who have difficulty in maintaining contact with services. However, they were unable to provide details of a specific model of care which they used. 7: User satisfaction and carer satisfaction with care arrangements are audited. STATUS: Partially met The service reported that it does audit user and carer satisfaction with care arrangements. However, this audit does not take place across the Trust. A pilot audit of the Care Programme Approach (CPA) has taken place. Desirable Criteria 8: Staff caring for people who have a diagnosis of schizophrenia are given the opportunity to receive specific training in caring for those who have difficulty in maintaining contact with services. STATUS: Not met (insufficient evidence) Data from the service indicated that staff are given the opportunity to receive specific training in caring for those who have difficulty maintaining contact with services. However, following discussions with staff on the day of the visit, and due to the differing perspectives and a lack of evidence, the review team concluded that it was unable to assess this criterion due to insufficient evidence. 9: A person s need for care and the outcomes of the care provided are assessed using validated rating scales which include a user perspective, e.g. CAN, AVON. STATUS: Partially met The Trust does assess a person s needs using validated rating scales. Functional Assessment of Clinical Environment (FACE) software, which is used as part of the ICP, incorporates a rating scale. However, the review team concluded, following discussion with staff, that this does not happen throughout the Trust. Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004 29

3. Detailed Findings Against the Standards Standard 5: Transferring Care - Admission to Hospital Standard Statement A person s care is transferred from community to hospital when the care and treatment that is provided within a hospital is required to meet the person s current needs and so improve their health and well-being. A person is involved in all aspects of their care throughout the time that they are in hospital. Those caring for the person both in the hospital and in the community work together, with the person, so that the care provided is based on the person s needs and will assist their early return to the community. Ayrshire & Arran Primary Care NHS Trust Essential Criteria 1: There are guidelines detailing the procedure to be followed when a person who has a diagnosis of schizophrenia is admitted to hospital on either an informal or compulsory basis. The use of these guidelines is audited. Standardised documentation is used to record the admission procedure. STATUS: Not met There are no guidelines detailing the procedure to be followed when a person who has a diagnosis of schizophrenia is admitted to hospital on either an informal or compulsory basis. The Trust does, however, have a nursing admission procedure. The review team agreed that standardised documentation is used to record the admission process. 2: When a person is admitted to hospital the following is undertaken: a) a psychiatric history, including an assessment of alcohol and illicit drug use; b) a general medical history; c) a mental state examination; d) a physical examination; e) an assessment of risk of harm to self and/or others, to be documented in the casenotes and used when deciding the appropriate level of nursing observation; f) an assessment of the carer s needs; and g) information is sought from the carer. STATUS: Partially met When a person is admitted to hospital, a psychiatric history, general medical history, mental state examination, physical examination, and risk or harm to self and/or others is undertaken. The review team concluded, following discussions with staff, that the carer s needs are not assessed on admission to hospital. The review team was unable to determine who triggers the formal process of assessing the needs of carers, if required. 30 Local Report (Ayrshire & Arran Primary Care NHS Trust): Schizophrenia - June 2004