Short Form Business Case for: S203 Wells Road Centre - Upgrade of Trent

Short Form Business Case for: S203 Wells Road Centre - Upgrade of Trent Nottinghamshire Healthcare NHS Trust 25 th January 2013

Document control sheet Client Document Title Nottinghamshire Healthcare NHS Trust, Rampton Hospital Short Form Business Case for S203 WRC Upgrade of Trent Version 3.0 Status - Reference - Author James Alexander/Andrew Latham/Rob Jones Date 28 th January 2013 Further copies from CPU Document history Version Date Author Comments 1.0 25 th January 2013 James Alexander/Andrew Latham/Rob Jones 2.0 19 th March 2013 James Alexander/Andrew Latham/Rob Jones 3.0 28 th March 2013 James Alexander/Andrew Latham/Rob Jones 4.0 23 rd April 2013 James Alexander/Andrew Latham/Rob Jones Presented to Capital Project Board Issue for F&P review Issue for Trust Board 5.0 6.0 7.0 8.0 9.0 10.0 Contact details Main point of contact Telephone number Email address Rob Jones 07939 203590 robert.jones@nottshc.nhs.uk S203 WRC Upgrade of Trent V4.0 2

Contents Figures 1 Executive Summary 4 2 Introduction 7 2.1 Purpose of Document 7 2.2 Clinical Context 7 2.2.1 Porchester Ward 7 2.2.2 Lister Ward 8 2.2.3 Thurland Ward 8 2.2.4 Seacole Ward 8 2.2.5 Trent Ward 8 3 Strategic Context 9 3.1 Introduction 9 3.2 The Trust 9 3.3 The Forensic Services Division 10 3.4 Low Secure and Community Forensic Directorate 10 3.5 National Strategic Drivers 11 3.6 Local Strategic Drivers 12 3.7 Strategic Partnership Market Intelligence 13 3.8 The Operational Environment Competitors 13 4. Project Overview and Deliverables 14 5 The Strategic Case 15 5.1 The Development of the Wells Road Centre 15 5.2 Current Environment 16 5.2.1 Porchester Ward 16 5.2.2 Lister Ward 17 5.2.3 Thurland Ward 17 5.2.4 Seacole Ward 17 5.2.5 Trent Ward 18 5.3 The Case for Change 18 6. Options 24 6.1 Option 1 24 6.2 Option 2 26 6.3 Option 3 28 6.4 Option 4 30 6.5 Option 5 32 6.6 Non-Financial Option Appraisal 34 6.7 Capital Estimates 35 6.8 Revenue Implications 35 7 Project Management 37 8 Conclusion 38 Figure 1 Income by Directorate (Forensic) Figure 2 Activity by Care Group (occupied beds days/community contacts*) Figure 3 Current ward names, patient numbers and the service provided Figure 4 Porchester Ward Photos Figure 5 Lister Ward Photos Figure 6 Seacole Ward Figure 7 Trent Ward Photos Figure 8 Trent Ward Layout Figure 9 Trent Ward Day Space Figure 10 Trent Option 1 Figure 11 Trent Option 2 Figure 12 Trent Option 3 Figure 13 Trent Option 4 Figure 14 Trent Option 5 Figure 15 Non-Financial Appraisal Scores Figure 16 Capital Costs Options 1 to 5 Figure 17 Finance Tables S203 WRC Upgrade of Trent V4.0 3

1 Executive Summary The central aim of this paper is to set out the arguments and evidence, to support the plans to invest up to 933k in the improvement of the patient environment on Trent Ward at the Wells Road Centre. The proposal is focused on enhancing the therapeutic environment and the advantages/resilience that this will provide the Trust such as providing better day space learning from the benefits associated with recently completed Wells Road Centre (WRC) schemes. The development is considered affordable to the Wells Road Centre (WRC) with an on-going revenue cost of 20k per annum. The Short Form Business Case (SFBC) has been tabled and recommended for approval at the Forensic Capital Monitoring Group meeting, and the major Capital Project Board. Over the past year the WRC site has become exclusively a Forensic Low Secure centre. In line with this clinical plan and the Estates Strategy objectives of improving efficiency, productivity, and quality of existing estate, the site has been updated with appropriate security infrastructure alongside incremental refurbishment schemes such as Porchester, Lister and Darwin wards. Trent ward accommodates 13 low secure beds for acutely unwell and newly admitted men. It acts as the acute admission and assessment ward for patients accessing the low secure in-patient service. All of the larger private provider competitors within the region have invested significant money into their patient accommodation, frequently expanding services with new buildings, built to high design specifications. To remain a market leading provider within this hugely competitive environment, the Low Secure and Community Forensic Directorate must, on behalf of the Trust, ensure that all patient accommodation is of the appropriate quality design and build standard. Trent ward currently falls a long way short of this very high standard. As the assessment ward for patients admitted to the WRC, patients admitted here are likely to display a high level of challenging and disturbed behaviour. Trent layout is a series of small corridors with rooms off them many set into the raised banking of the site. There is very little natural light and of the 13 bedrooms only 6 have en-suite facilities. The day space available for patients is very limited and contributes to a feeling of overcrowding. Figure The psychiatric hospital environment can play a significant, if often under-recognised, role in patient and staff functioning. High-quality care and positive clinical outcomes in in-patient psychiatric treatment necessitate a broad conceptualisation of forces that lead to therapeutic changes that include attention to environmental design. S203 WRC Upgrade of Trent V4.0 4

Poor accommodation and security, safety concerns, insufficient staffing levels and intense boredom all exacerbate existing difficulties and create new ones. Trent has three times the frequency of verbal and physical aggression than the other wards on site and the impact and severity of assaults is much greater, with resultant seclusions. Within the hospital, incidents of self-harm are almost exclusively within Trent ward. Within the Forensic Division by far the highest rate of violent incidents is by patients against staff. It is notable that on Trent ward the highest rate of violent incidents is between patients. This results in frequent periods of patients being nursed on high observations and, due to the standard of the environment with its inadequate observation of patients, a degree of increased staffing costs. The areas of concern regarding the existing patient environment on Trent Ward: Available space for patients to circulate. Capacity for staff to observe patient behaviour Lack of en-suite facilities in bedrooms. Inconsistency of patient safety with regard to anti-ligature and anti-barricade. With regards to the local priorities and the service development plans associated with the WRC, the service aims to be a provider of choice for the Commissioners. The key factor for that choice is that the placement of a patient at the Wells Road Centre is based on the Commissioners being confident that the service has the experience, expertise and facilities to satisfactorily manage the risk and is able to provide treatment programmes which maximise the potential for each patient. This project would make a significant improvement to those facilities and have a significant positive effect on staff and Commissioner confidence and will provide a consistent level of care environment across the hospital, complementing the environment and service provided on the treatment wards Thurland and Porchester. Consequently, the project deliverables are: Step change to improve the existing day space environment of the Male Mental Illness assessment ward at the WRC. Provide en-suite accommodation to all beds within the ward so removing the two tier accommodation currently available on the ward. Open access to a remotely observed courtyard area; allowing patient freedom of movement and access to outside areas and fresh air. Trent Ward continues to provide and improve on the current level of care enabling minimal stay on the assessment ward. To demonstrate improvements in cases of IR1 and of seclusion through improved environment and clinical practice. Bring the care environment up to date to comply with national standards. Improve safe observation and therefore patient and staff safety and allow improved utilisation of staff time and demand on additional bank staff. Enhance the privacy and dignity of patients on Trent ward to comply with national standards regarding en-suite facilities. Enhance the reputation of the Trust and preserve the role of the Low Secure and Community Forensic Directorate as a market leader. To ensure and standardise current anti-barricade and anti-ligature standards. S203 WRC Upgrade of Trent V4.0 5

A large number of layout options were tabled and reduced to five (including two without en-suite provision) for more detailed review within the SFBC. Under a non-financial review Option 3 was considered to deliver the objectives most fully: Opening up day space and provide observation to the Courtyard providing 127m 2 of day Space, all of which in an open useable squared area, with new large windows and doors to the open Courtyard. Creating a single large Therapy/Games room. Creating a new Interview room, inclusive of an observation window from the new Staff Base. Creating a new Servery, Beverage point and Staff Base. Relocating the entrance to Trent Ward. Potential for conversion of the existing kitchen into a quiet room or bedroom with en-suite. Dividing two existing bedrooms in half to form en-suites to adjacent bedrooms. Converting the existing seclusion facility into a standard bedroom by reproviding it in the communal bathroom/shower areas. Extending the Bankside meeting room to create an MDT meeting room. Relocate the interconnecting door to Porchester to create male and female Staff WCs (existing) within the staff only corridor between Porchester and Trent Capital cost estimates, based on market tested square meterage rates, are 933k, allowance for which is included within the Trust Capital Budget. While the majority of which is expected to be spent 2013/14, the extended program due to the inability to decant the ward will extend the program and in the order of 110k is expected to be spent 2014/15. Long term operating costs should have little change. Delivery of the scheme will be via Forensic Facilities, through the Minor Block Capital process. The scheme progress and financial accounting will be reported by Facilities through the Forensic Capital Planning and Monitoring Group. S203 WRC Upgrade of Trent V4.0 6

2 Introduction 2.1 Purpose of Document 2.1.1 The central aim of this paper is to set out the arguments and evidence, which will lead to support for Nottinghamshire Healthcare NHS Trust plans to invest in the improvement of the patient environment on Trent Ward at the Wells Road Centre. 2.1.2 The Wells Road Centre is a well established and experienced provider of Low Secure Services and looks continuously at ways of improving the quality of the environment and clinical services provided to patients. 2.1.3 The Business Case will argue the case for change focussing on the physical environment and the impact this has on patient care, staff morale and ward atmosphere. 2.1.4 The paper will describe in short 5 options by which the authors feel the environment of Trent Ward could be improved to have a positive effect on patient outcomes. 2.1.5 These options will be appraised using the SFBC non financial model and the preferred option will be described in greater detail outlining a cogent case for preference. 2.1.6 There is a section which considers project management to provide assurances that the Low Secure and Community Forensic Directorate possess the knowledge skills and experience to implement such a proposal. 2.1.7 The hospital was built in 1993 in the grounds of an existing Psychiatric hospital. Until 2011 the site was mixed use, housing 3 Forensic Wards, 1 General Psychiatric Admission Ward, a Substance Misuse ward, a Substance Misuse Day Hospital and Pharmacy and support functions. 2.1.8 Over a number of years there have been changes to the fabric of the building in an attempt to improve patient safety and security and privacy and dignity within the Forensic wards. 2.1.9 In the past year the site has become exclusively a Forensic Low Secure Hospital. Accordingly there have been further programmes of improvement and refurbishment, inclusive of the extensive refurbishment of Porchester and Lister wards, completed in 2012, providing large open day space areas and en-suite accommodation. Plus a current Minor Block upgrade of Seacole. 2.2 Clinical Context 2.2.1 Porchester Ward 20 low secure beds for men requiring enhanced rehabilitation. Porchester ward offers the same treatment interventions and enhanced living skills as its sister ward, Thurland. It focuses, however, on providing these interventions over a longer period of time and with more repetition to help patients develop skills in their risk management and coping techniques. Patients benefit form an extensive social and recreational living space including a multi functional therapy and dining area. The accommodation is of an exceptional quality and, being built around a large courtyard, has a light and airy atmosphere, as well as offering large, well appointed, en-suite bedrooms. S203 WRC Upgrade of Trent V4.0 7

Patients on Porchester will access therapies and activities off the ward and in the community. 2.2.2 Lister Ward The accommodation is of an exceptional quality and, being built around a large courtyard, has a light and airy atmosphere with the ability to split the day space into two contained areas, as well as offering large, well appointed, en-suite bedrooms. The accommodation has been designed, built and decorated to enhance the therapeutic effect and reduce the stress that can be caused by a living environment which can be especially prominent in those with autistic spectrum and a learning disability. The garden area offers opportunities to participate in horticulture, relaxation and exercise. A wide range of therapy and activities away from the ward is also available across the range of communal facilities within the Wells Road centre. 2.2.3 Thurland Ward 20 low secure beds for men requiring rehabilitation and discharge. Thurland ward offers treatment and recovery focussed rehabilitation programmes designed to reduce risk and increase individual skills for problem solving, anger control and dealing with substance misuse. These bespoke treatments are essential components needed to enhance patients skills for living in order to set them on a road to recovery and return to a life in the community. Patients on Thurland ward have access to therapies and activities off the ward and to resources within the community on an individually risk assessed basis. There is a focus on social roles such as work and education. 2.2.4 Seacole Ward Seacole ward is currently undergoing a refurbishment to create accommodation for women who are cared for by community forensic teams and who require a period of low secure care. The ward will offer full en-suite accommodation, a large self contained dining area, group room, TV lounge, extensive garden areas for horticulture, recreational activities, covered areas and a small pet area. Situated on the first floor of the building on an external wall, it is not overlooked by any other patient areas, ensuring care and treatment is delivered in a discreet and private manner. The ward is adjacent to a large occupational therapy area offering bespoke treatment and social and recreational areas for use by the female patients only. A wide range of non gender specific therapy and activity is also available away from the ward across the facilities within the Wells Road centre. 2.2.5 Trent Ward 13 low secure beds for acutely unwell and newly admitted men. Trent ward acts as the acute admission/assessment ward for patients accessing the low secure in-patient service. There are a range of therapeutic programs in a safe, calm environment conductive to treatment. Following risk assessment, patients on Trent ward can access therapies and activities off the ward. S203 WRC Upgrade of Trent V4.0 8

3 Strategic Context 3.1 Introduction 3.1.1 The NHS has enjoyed a prolonged period of growth. However, it is recognised that this period has now ended and, while NHS funding is currently notionally protected, real terms cuts are anticipated. Ensuring that high quality services are delivered in the most productive, efficient and value for money way has always been an objective of the NHS, but the financial constraints likely to arise in the future places greater emphasis on achieving cost improvements while maintaining the quality of services. 3.1.2 The White Paper Liberating the NHS stresses the requirement for efficiency gains through the achievement of quality standards leading to improved patient outcomes. In addition to these financial pressures, under the White Paper Commissioning arrangements are undergoing fundamental change with, in particular, local Commissioning PCTs being replaced with new GP led bodies. The NHS is entering a period of upheaval and financial uncertainty forming part of the backdrop to this case. 3.2 The Trust 3.2.1 Nottinghamshire Healthcare NHS Trust in November 2010 was confirmed as meeting Foundation Trust Standards and is one of the largest mental health and learning disability providers in the UK. The Trust is currently divided into three Divisions; Local, Forensic and Community Health Partnerships. It provides a range of services in settings that vary from the community, through acute wards and residential units. The Trust employs in the order of 8800 staff at over 100 sites and has a revenue income of 414m for 2011/12. 3.2.2 In the Care Quality Commission Patient Satisfaction Ratings, 80% of service users rated the care they received from Nottinghamshire Mental Health Trust as excellent, very good or good, putting it in the top 20% of Trusts in the country. The Trust now has over 8000 public members with a Members Council recruited in 2010 to guide decision making. The Trust won the first Patient Experience National Network Awards in the category Setting the Stage/Strengthening the Foundations. The Trust achieved approx 25,000 Out-patient appointments and approximately 378,000 Community contacts for 2010/2011, with approximately 188,000 Occupied Bed Days (excluding Medium & High Secure). Nottinghamshire Healthcare NHS Trust has recently become an integrated healthcare provider. It provides a wide range of services from primary care through to high secure mental health and learning disabilities and includes substance misuse in its portfolio. Services are delivered in settings that range from the community, through acute wards and high secure services at Rampton Hospital. The Trust is rapidly becoming a leading provider in offender healthcare. 3.2.3 The Trust has a relatively large existing estate across the region of Nottinghamshire, Leicestershire and South Yorkshire, comprising a geographically and functionally diverse property portfolio. Prior to the introduction of the Community Health Partnership, care was delivered from 205 individual properties (98 buildings in the Forensic Division on 4 sites and 107 in the Local Division on 68 sites) across Nottinghamshire. The services and the functionality of this range of properties are very diverse and, notably, there are 106 inpatient wards and/or residential units within the portfolio. This estate has significantly increased since the introduction of Community Health Partnership. S203 WRC Upgrade of Trent V4.0 9

3.2.4 The Trust Estate Strategy is focussed on improving the efficiency of its existing estate to achieve improved clinical outcomes and realise savings. This is encapsulated in a preferred model of estate utilisation based on a hub and spoke approach to service delivery. The Trust anticipates continuing the reduction of the number of sites from which it operates. 3.3 The Forensic Services Division 3.3.1 The Forensic Services Division represents the largest NHS forensic portfolio in the Country. 3.3.2 The Forensic Division is known for its provision of unique and innovative services and is in the rare position of providing services across a full spectrum of secure hospital care (high, medium and low). 3.3.3 The Division currently holds an annual budget of over 103 million and employs 2372 staff. 3.3.4 In summary, the Division provides: Community forensic services Criminal Justice Liaison service Community Personality Disorder Treatment and Case Management service Low secure in-patient beds at the Wells Road Centre Medium secure in-patient beds at Arnold Lodge and Wathwood Hospital High secure in-patient beds at Rampton Hospital Prison in-reach services. 3.4 Low Secure and Community Forensic Directorate 3.4.1 The Low Secure and Community Forensic Directorate provide a county-wide, specialist forensic service to individuals who pose a risk of harm to others in the context of their mental disorder. 3.4.2 The service provides 69 Low Secure in-patient beds on four wards at the Wells Road Centre and 7 pre discharge rehabilitation beds. 3.4.3 It is the market leader for male mental illness provision in the region and almost all Nottinghamshire Low Secure men are cared for at the Wells Road Centre. 3.4.4 A fifth ward providing a new women s in-patient service is to open in April 2013. 3.4.5 The Service has two community teams providing individual case management to 120 patients in the city of Nottingham and throughout the county of Nottinghamshire. 3.4.6 Currently, male only low secure in-patient services are provided in Nottingham. Low secure units deliver intensive, comprehensive, multidisciplinary treatment and care for patients who demonstrate challenging and harmful behaviour in the context of a serious mental disorder and who require the provision of appropriate security underpinned by the principles of rehabilitation and risk management. 3.4.7 The Directorate provides in-reach Criminal Justice Liaison teams working to provide a service focusing upon providing alternative to custody for men and women from across the county. 3.4.8 Specialist community treatments and interventions for Personality Disordered men and women. S203 WRC Upgrade of Trent V4.0 10

3.4.9 A close working partnership with criminal justice agencies, adult social care and health, other trust directorates and the voluntary sector is essential for the effective and safe delivery of these services. Figure 1 Income by Directorate (Forensic) FORENSIC Forensic income in 2009/10 Low Secure Community Forensic Directorate 6,695,725 Forensic Psychiatry 1,226,825 Offender Health within Prisons 715,814 Medium Secure Services 23,823,942 Medium Secure Services - Women's Enhanced 2,799,312 High Secure Unit : Women's Services 16,098,398 High Secure Unit : Mental Health 28,049,317 High Secure Unit : Learning Disabilities 14,393,925 High Secure Unit : Personality Disorder 15,911,654 High Secure Unit : DSPD 18,558,642 Deaf Services Forensic 445,866 Total Forensic 128,719,420 Figure 2 Activity by Care Group (occupied beds days/community contacts*) 3.5 National Strategic Drivers 3.5.1 Since April 2010, MESCG (Midlands and the East Strategic Commissioning Group) has had responsibility for commissioning Low Secure Services whilst the community and predischarge step down elements of the Forensic Service continue to be locally commissioned by the PCT (Primary Care Trust)/CCG s (Clinical Cluster Groups) in Nottinghamshire with NHS Nottingham City acting as the lead commissioner. 3.5.2 The 2012 Health and Social Care Act heralds changes in the commissioning landscape to be implemented across 2012/13, with National Commissioning Boards (NCB s) in place by the end of the financial year. The NCB will formally devolve the majority of the commissioning responsibility from Strategic Health Authorities and PCT s to clinician led Clinical Cluster Groups. The plan is to put the clinicians at the heart of the new commissioning body and backbone of the NHS. These CCG s will assume the responsibility of purchasing locally relevant services and bespoke packages of care for the local populace. S203 WRC Upgrade of Trent V4.0 11

3.5.3 In some specialist care provision cases the responsibility for commissioning services will not rest with the CCG but will be devolved to regional specialist commissioning bodies, including the MESCG. The final decision on the sphere of responsibility for these regional specialist commissioning bodies is not yet finalised. There is, however, a growing feeling that all Forensic services should be commissioned by them. 3.5.4 If this comes to fruition then the responsibility for commissioning all aspects of the Directorates services will lie with a single body and should enhance the strategic planning of integrated services, with the focus being effective patient pathways into the community. 3.5.5 This synergy of commissioning will complement the Directorates core services (Low Secure in-patient, Pre-Discharge step down rehabilitation, and comprehensive Forensic Community case management) and enhance the patient pathway available for Nottinghamshire patients. 3.6 Local Strategic Drivers 3.6.1 The MESCG has taken a strategic view of low secure provision across the region and has looked at issues of contestability, such as value for money, quality & outcome measures, performance against KPI s and customer service. 3.6.2 The Low Secure & Community Forensic Directorate is currently one of the main providers of Low Secure care within the region. As such we have recently negotiated with the MESCG to participate in the strategic partnership it currently enjoys with the Trust Medium Secure Site, based in Leicester. 3.6.3 The Strategic Partnership enables devolved gate keeping responsibility to be granted to an organisation and clinicians within it. The Gatekeepers then work strategically with the Commissioners to look at all Low Secure placements within the region and assess their suitability. 3.6.4 The aim of the partnership is to ensure that patients experience the very best care that is available to them, as close to home as possible, at the best price possible. Where this does not occur, processes are put in place to relocate the patient to a more suitable environment. 3.6.5 Historically, Arnold Lodge, the Trusts Medium Secure site, works in partnership to manage all Medium Secure placements for men with a Mental Illness, for men with Personality Disorder, women patients that require in-patient care, plus Learning Disability men and women, across the East Midlands region. 3.6.6 The MESCG strategic partnership with the Low Secure and Community Forensic Directorate replicates these patient pathways gate keeping models, risk sharing and efficiency aims, and would ensure that the Directorate has oversight over all Low Secure placements across the full range of patient groups throughout the region. 3.6.7 The Directorate is tasked with directly influencing a reduction in the total Low Secure budget expenditure ( 16m) across private and NHS providers of care for Nottinghamshire patients. In-depth knowledge of bed day prices, length of stay and treatment costs/specialities are implicit within this agreement. 3.6.8 It also places the Directorate gate keepers as the main advisers to the commissioners, assessing the appropriateness of placements, dependent on treatment offered, proximity to home and value for money. S203 WRC Upgrade of Trent V4.0 12

3.6.9 This model would ensure that awareness of the Low Secure market place would become complete, including pricing structures, location, length of stay and patient progress through their pathway. 3.7 Strategic Partnership Market Intelligence 3.7.1 Analysis of those patient populations and distribution through private providers highlighted by the strategic partnership indicates there is an opportunity to grow this aspect of the Trust s business. 3.7.2 The Low Secure and Community Forensic Directorate are recognised as preferred providers to both East and West Midlands, providing 53 male Mental Illness beds to the MESCG, with an associated income of 6.5m. 3.7.3 There is clear evidence, however, that an additional 9,427,758 per annum is being spent by Commissioners buying Independent Sector Low Secure beds for Nottinghamshire patients which are either at a distance from Nottinghamshire or often of poor quality. These beds are also demonstrably expensive with additional charges for extra services such as additional observations, psychological intervention or atypical antipsychotic drugs. 3.7.4 The strategic partnership empowers the Directorate to regularly analyse the Out of Area (OAT s) populations that make up the independent sector expenditure identified above. It is clear from this analysis that there are a significant number of Nottinghamshire Mentally Ill men, women, and Learning Disabled men that currently receive care in private providers. All these patients are residents of Nottingham City and County, and should be offered care as close to their home as possible. 3.7.5 As a result, the Directorate has expanded its bed numbers and services to provide services for men and women from the region suffering from mental illness, plus Learning Disabled men. 3.7.6 These markets are extremely competitive within the region and as such the Directorate must assert our excellence in patient care, outcomes and cost, but must also provide care for our patients in high quality accommodation that is equivalent, if not superior, to private provider competition. 3.7.7 As such the unit has experienced significant investment from the Trust and now boasts four wards of exceptional build quality, complimented by a fully refurbished pre discharge facility. 3.7.8 The acute admission ward does not, however, achieve these standards. It is confined with little social and recreation space, has poor ability to complete remote observation and has small bedrooms without en-suite facility for the majority of the patients. 3.8 The Operational Environment Competitors 3.8.1 There are a number of local NHS providers of services similar to those that the Trust provides. They can be seen as potential competitors in that they do respond to tenders for services from Commissioners for either services currently provided by the Trust or new services that the PCTs wish to commission, or they develop relationships with PCTs or practice based consortia to provide marginal services around the borders of the Trust. S203 WRC Upgrade of Trent V4.0 13

3.8.2 Nationally, the top four private providers of mental health and learning disability services are; Priory Group, Partnerships in Care, the charitable St Andrew s Group, and Cygnet Health Care. They operate 39% of independent mental health hospital beds as at mid- 2008, and generated an estimated 55% of sector revenue in and around a base year of 2007. 3.8.3 By this measure, the independent mental health hospital sector has a somewhat lower market concentration than the acute medical/surgical hospital sector, where the top 4 providers generated 62% of revenue in 2007, but is much more concentrated than the care home sector for mentally ill and learning disabled people, where the top four have just 8% of capacity. 3.8.4 St Andrew s Group are our largest competitors for male mental illness and learning disability in the Medium and Low Secure market. They have a strong operational base within Northamptonshire and have recently (2010) opened a national Low and Medium secure facility for learning disabled men in Mansfield. 3.8.5 The Raphael Group provide services for women across the region and are our largest competitors for this patient population. They provide 100% of the Low Secure beds for local residents, despite the fact that all these women remain on the case load of the Directorate s Community Forensic teams. 3.8.6 Local Private providers provide 46 Low Secure beds for Nottinghamshire men and women and as such receive 56% ( 9.4M) of the overall Low Secure spend from the MESCG. 3.8.7 All of the larger private provider competitors within the region have invested significant money into their patient accommodation, frequently expanding services with new buildings, built to high design specifications. 3.8.8 To remain a market leading provider within this hugely competitive environment, the Low Secure and Community Forensic Directorate must, on behalf of the Trust, ensure that all patient accommodation is of the highest quality design and build standard. 3.8.9 Trent ward currently falls a long way short of this very high standard. 4 Project Overview and Deliverables 4.1 In the past year the site has become exclusively a Forensic Low Secure Hospital. Accordingly there have been further programmes of improvement and refurbishment, inclusive of the extensive refurbishment of Porchester and Lister wards, completed in 2012, providing large day space areas and en-suite accommodation. Plus a current Minor Block upgrade of Seacole. During this transition to a secure site there has been an increase in patient population and the programmes of work have improved physical security and the patient experience with the associated improved staff and patient outcomes. 4.2 The proposed refurbishment development of Trent ward will enhance the service provision to patients in the Male Mental Illness Care Stream at the Wells Road Centre. 4.3 These improvements are specifically associated with the care of patients upon admission to the hospital and will provide a consistent level of care environment across the hospital, complementing the environment and service provided on the treatment wards Thurland and Porchester. S203 WRC Upgrade of Trent V4.0 14

4.4 The proposed improvements will address the current problems experienced with the environments and will move towards achieving as many of the building standards associated with Low Secure Units as possible within the existing structure, given that the scheme is a refurbishment project and not a new build. 4.5 In summary, the project deliverables are: Step change to improve the existing day space environment of the Male Mental Illness assessment ward at the Wells Road Centre. Provide en-suite accommodation to all beds within the ward (options 3 and 4) so removing the two tier accommodation currently available on the ward. Trent Ward continues to provide and improve on the current level of care enabling minimal stay on the assessment ward. To demonstrate improvements in cases of IR1 and of seclusion through improved environment and clinical practice. Bring the care environment up to date to comply with national standards. Improve safe observation and therefore patient and staff safety. Enhance the privacy and dignity of patients on Trent ward to comply with national standards regarding en-suite facilities. Enhance the reputation of the Trust and preserve the role of the Low Secure and Community Forensic Directorate as a market leader in in-patient care by providing a care environment comparable to local competitors. To ensure and standardise current anti-barricade and anti-ligature standards throughout the affected areas (majority of the ward). Improve observations within the ward and into the existing courtyard to allow improved utilisation of staff time and demand on additional bank staff. Options 1 and 2 provide the opportunity to increase overall site bed numbers by 1 if deemed desirable. 5 The Strategic Case 5.1 The Development of the Wells Road Centre 5.1.1 Wells Road Centre currently has 76 beds and employs around 180 staff. The in-patient wards are organised into 4 care streams; male mental illness, male learning disability and a 3 rd stream of 15 women s beds due to be opened in April 2013, plus a pre discharge unit. Figure 3 - Current ward names, patient numbers and the service provided Ward Patients Gender Service Trent 13 Male Assessment and Treatment Thurland 20 Male Rehabilitation (Mental Illness) Porchester 20 Male Rehabilitation/continuing care (Mental Illness) Lister 16 Male Learning Disability Prospect House 7 Male Rehabilitation / Pre-Discharge Seacole 15 Women Due to open April 2013 Total 91 76 with a further 15 to open April 2013 S203 WRC Upgrade of Trent V4.0 15

5.1.2 In the 20 years since opening, The Wells Road Centre has undergone a number of capital development projects of varying sizes and complexities and since 2009 has pursued a phased programme of refurbishment in a transition from an open, mixed use site to a modern Low Secure Hospital. The subject of this Business Case is to upgrade the assessment ward (Trent Ward) of the hospital in line with these developments and in doing so afford the opportunity to provide a consistent care environment across the hospital and maintain a competitive position in the market place. 5.1.3 These developments have been at the core of the Integrated Business Plan for the service and are a key element in the long term strategy. Such developments have been crucial in ensuring that clinical quality can be facilitated and maintained through environmental improvement. It also ensures that services can be delivered in safe and health enhancing surroundings which are sufficiently flexible to keep pace with changing health related trends and clinical demands, including the increasingly complex presentations which are apparent within the clinical population. 5.1.4 The case for change has been prompted by the service s intention to ensure that clinical care is of the highest standard and is delivered in environments which reflect and enable this high standard. 5.1.5 With regards to the local priorities and the service development plans associated with the Wells Road Centre, the service aims to be a provider of choice for the Commissioners. The key factor for that choice is that the placement of a patient at the Wells Road Centre is based on the Commissioner being confident that the service has the experience, expertise and facilities to satisfactorily manage the risk and is able to provide treatment programmes which maximise the potential for each patient. This project would make a significant improvement to those facilities and hopefully have a significant positive effect on staff and Commissioner confidence. 5.2 Current Environment 5.2.1 Porchester Ward Porchester ward was vacated in 2010/11 when the Substance Misuse Service relocated to Highbury Hospital. During 2011/12, the ward has been completely re-modelled to provide a modern, fit for purpose ward to accommodate 20 of the Directorate s longer stay male patients. The ward has been designed to provide open living spaces, en-suite bedrooms, CCTV coverage, good observations, anti-barricade doors locks, etc. S203 WRC Upgrade of Trent V4.0 16

Figure 4 Porchester Ward Photos 5.2.2 Lister Ward Lister ward was vacated in April 2011 when the Adult Mental Health ward relocated to Highbury Hospital. During 2011/12 the ward has been completely re-modelled to provide a modern, fit for purpose ward to accommodate 16 male patients with a Learning Disability requiring conditions of Low Security. The ward has been designed to provide open living spaces, en-suite bedrooms, CCTV coverage, good observations, anti-barricade doors locks, etc. Figure 5 Lister Ward Photos. 5.2.3 Thurland Ward Thurland ward was re-modelled in 2009 to provide open living spaces, 5 en-suite bedrooms, improved access to bedrooms, improved observations and anti-barricade doors. 5.2.4 Seacole Ward Seacole ward is currently being re-furbished to provide a modern, fit for purpose ward to accommodate 15 female patients. During the refurbishment, patient safety concerns such as ligature risks and observation are being addressed. CCTV is to be fitted and the living spaces are being opened up to provide a pleasant patient environment with good observations. S203 WRC Upgrade of Trent V4.0 17

Figure 6 Seacole Ward 5.2.5 Trent Ward Trent ward is the assessment ward for patients admitted to Wells Road, as such patients admitted here are likely to display a high level of challenging and disturbed behaviour. Trent is laid out as a series of small corridors with rooms off them some set into the raised banking of the site. There is very little natural light and of the 13 bedrooms only 6 have ensuite facilities. The day space available for patients is very limited and contributes to a feeling of over crowding. Work has been agreed to install CCTV and carry out further anti-ligature modifications to the ward, this will go some way to address some of the patient safety issues on the ward. Figure 7 Trent Ward Photos 5.3 The Case for Change 5.3.1 Research findings and clinical conjecture reported over the past 50 years have indicated that the psychiatric hospital environment can play a significant, if often under-recognised, role in patient and staff functioning. High-quality care and positive clinical outcomes in inpatient psychiatric treatment necessitate a broad conceptualisation of forces that lead to therapeutic changes that include attention to environmental design. S203 WRC Upgrade of Trent V4.0 18

Best Practices: Environmental and Therapeutic Issues in Psychiatric Hospital Design: Toward Best Practices Bradley E. Karlin; Robert A. Zeiss Psychiatric Services 2006; doi: 0.1176/appi.ps.57.10.1376 For others, poor accommodation and security, safety concerns, insufficient staffing levels and intense boredom exacerbate existing difficulties and create new ones, subjecting patients to an environment that is inhumane where it should be therapeutic. MIND Ward Watch 5.3.2 Patients within Forensic Secure settings tend to deal with interpersonal conflict with an aggressive response, there are inevitably a level of incidents of violence and aggression on the wards. Within the Forensic Division by far the highest rate of violent incidents is by patients against staff. It is notable that on Trent ward the highest rate of violent incidents is between patients. Trent has three times the frequency of verbal and physical aggression than the other wards on site and the impact and severity of assaults is much greater, with resultant seclusions. It could be expected that if we can change the patient environment, reduce feelings, overcrowding and resultant stress and interpersonal conflict, this would impact on this. Within the hospital, incidents of self harm are almost exclusively within Trent ward. This results in frequent periods of patients being nursed on high observations and, due to the standard of the environment with its inadequate observation of patients, a degree of increased staffing costs. 5.3.3 It is generally accepted that the design and quality of the environment can have positive outcomes for those with Mental Illness. Such gains have included an increase in feeling safe, improved sense of autonomy, individuality, dignity, privacy and comfort. An open plan lounge with clear observation into the courtyard would lead to enhanced observation of patients and an improved patient experience. 5.3.4 At the time of the hospital s original opening, the part of the site currently Trent ward was not a ward but was offices. The design and specification of this section of the hospital was that which fitted use as offices, the ward is laid out as a series of small corridors with rooms off them some set into the raised banking of the site. There is very little natural light and, following conversion to a ward, of the 13 bedrooms only 6 have en-suite facilities. Since the ward was converted from office space in 1998 there has been a great deal of remedial work in an attempt to bring the environment in line with the changing patient safety and security standards of a modern Low Secure Hospital. Remedial works have resulted in a patchwork of provision which differs significantly within the ward itself and from the newer built or refurbished areas of the Hospital. This no longer fits with the requirement to provide services for an increasingly challenging and demanding group of patients. S203 WRC Upgrade of Trent V4.0 19

Figure 8 Trent Ward Layout S203 WRC Upgrade of Trent V4.0 20

5.3.5 Key areas of concern regarding the existing patient environment on Trent Ward: Available space for patients to circulate. Capacity for staff to observe patient behaviour. Lack of en-suite facilities in bedrooms. Inconsistency of patient safety with regard to anti-ligature and anti-barricade. 5.3.6 Circulation Space Currently the available internal space for 13 patients to circulate on the ward is 72m 2 of which some 26m 2 is unusable corridor. There is no natural light or ventilation (external windows) within this space other than an end of corridor door to the court yard. Figure 9 Trent Ward Day Space Understandably this contributes towards a feel of overcrowding, this can negatively impact on the mental state of individuals who may be sensitive to noise, over stimulation and find living with people in such close proximity difficult. In turn these conditions can lead to patient confrontation and aggression. Trent Ward has 2 external spaces available for patients, a paved courtyard internal to the building and a turfed area adjacent to the perimeter fence. These areas cannot be observed from the main spaces of the ward so patients must be supervised whilst using them, this reduces the amount of time patients are safely able to use these spaces. S203 WRC Upgrade of Trent V4.0 21

5.3.7 Observation The layout of the Wards makes direct observation of patients difficult; the ward consists in the main of 3 corridors. There is no clear observation from the staff base into the patient circulation areas. The Directorate has a robust Observation Procedure and there is no doubt that open and observable space on a ward not only facilitates the formal routine observations of individual patients carried out by staff teams but also provides good on-going general observation of the patient group. Inadequate observation on a ward such as Trent has a significant impact on the function of the ward. The security of the hospital can be compromised if patients can not be observed sufficiently, contraband can be passed, and there is increased opportunity to interfere with the fabric of the building. Trent is the assessment ward and, as such, the observation of patient behaviour is crucial. The clinical team can only build up a clear picture of the patient s mental health by comprehensive information gathered by nursing staff based on their observations of patients. The patients on Trent ward are likely to present the highest risks and the more challenging behaviour of the patient population within the hospital, inadequate observation of these patients can allow situations between patients to escalate. 5.3.8 En-suites Of the 13 bedrooms on Trent only 6 currently have en-suite facilities. From a privacy and dignity standpoint it is clearly desirable to strive for en-suite facilities throughout the Hospital. Recent upgrade works have resulted in some increase in the en-suite rooms on Trent and other wards. From a patient perspective, the living environment on Trent ward is not to the same standard as environments enjoyed by other patients within the hospital, or that provided by the competition outside the Trust. From the perspective of the staff, providing an environment which reflects the clinical management needs of a group of patients is likely to increase confidence in safety and allow deployment of resources into therapeutic contact with patients rather than having to physically manage the environment in order to make it safe. Improvements in an environment which addresses issues such as safety and comfort are also likely to improve work satisfaction and morale. S203 WRC Upgrade of Trent V4.0 22

5.3.9 Patient safety, Anti-ligature and Anti-barricade work Funding has been made available previously to carry out priority patient safety works on Trent Ward. Install CCTV cameras. Replace outdated light fittings with anti-ligature fitting as used across Division. Fit more robust bedroom door architrave. Fit new courtyard door. Install hatch in sharps store door (new door required). Remove doors to bedroom en-suites. Remove bath in en-suite. Replace opening mechanism to Vistamatic vision panels, to match other wards. Replace opening mechanism on anti-barricade device, to match other wards. Make flush in ceiling Ascom attack alarm sensors. The current planned investment is sufficient to address immediate patient safety concerns but as with previous schemes it does not address the general layout of the ward and other issues detailed in this case. This schedule of improvements has been planned in such a way as to not compromise any more wide-ranging work should this Business Case be successful. S203 WRC Upgrade of Trent V4.0 23

6 Options Options for the delivery of a modern, fit for purpose, low secure environment with high standards of patient safety, security and privacy and dignity. 6.1 Option 1 Relocate the entrance to Trent Ward towards the main Hospital central corridor, incorporating the Bankside meeting room within the ward boundary. Remove the existing outer ward boundary door and screen. The Bankside meeting room to be extended to create a room large enough to be used as an MDT meeting room, this would be used for Ward Rounds, Clinical Reviews and Tribunals. An alternative restaurant fire exit would need to be created. The existing TV Room to be converted to a new Staff Base. Including installation of 3 vision panels to improved observation of Day Space and Bedroom Corridor and new Interview room. Door to open outwards. Opens up day space and provide observation to the Courtyard by removing the two staff WC s, Dining Room and Activity Room. Increase the size of the window to provide observation into the Courtyard from the ward area. Create a single large Therapy/Games room by removing the dividing wall between the two offices adjacent to the new staff base. Convert the existing locker room into an Interview room, inclusive of an observation window from the new Staff Base. Convert the existing Store and WC adjacent to the ward entrance to a Servery and Beverage point (one room, blocking up the door to the Clinic). The existing kitchen is then available to be converted to a Relaxation room. Relocate the interconnecting door to Porchester to create male and female Staff WCs (existing) within the staff only corridor between Porchester and Trent. This option would provide 127m 2 of day Space, all of which in an open useable squared area, with windows and doors to the open Courtyard. Area affected for refurbishment 310m 2 S203 WRC Upgrade of Trent V4.0 24

Figure 10 Trent Option 1 S203 WRC Upgrade of Trent V4.0 25

6.2 Option 2 Relocate the entrance to Trent Ward towards the main Hospital central corridor, incorporating the Bankside meeting Room within the ward boundary. Creates a new Staff Admin Office from the existing Store and WC adjacent to the ward entrance. Relocate the second entrance door to Trent Ward observable from the Day Space and this Staff Admin Office. Opens up the Day Space to provide spacious, open, naturally lit patient area by: o Removing the existing Staff Base, Quiet Room and TV Room. o Removing the external wall and extending the ward into area currently unused at the back of the restaurant. In this area build an Atrium room, this room to have a number of large windows to maximise natural light. o Utilising the space up the restaurant wall, the existing fire exit (restaurant) to be reprovided. A new Staff Base to be created from the existing Dining Room including removal of 2 Staff WC s, inclusion of vision panels and an additional window on to Courtyard to provide the Staff Base with observations of Day Space, Bedroom Corridor and Courtyard. A new servery to be provided within the existing Locker room. The existing kitchen is then available to be converted to a Relaxation room. This option would provide in the order of 192m 2 of day Space, with windows to external space and of which 24m 2 would be unusable corridor. Area affected for refurbishment 326m 2 S203 WRC Upgrade of Trent V4.0 26

Figure 11 Trent Option 2 S203 WRC Upgrade of Trent V4.0 27

6.3 Option 3 As per Option 1 with the addition of works on bedrooms to provide 13 en-suite bedrooms (noting that 1 bedroom en-suite may be small). These rooms to be constructed to the same standard and specification as recent work on Lister and Porchester Wards. o o o Conversion of the existing kitchen into a bedroom with en-suite. Dividing two existing bedrooms in half to form en-suites to adjacent bedrooms. Converting the existing seclusion facility into a standard bedroom by reproviding it in the communal bathroom/shower areas. This option would provide 127m 2 of day Space, all of which in an open useable squared area, with windows and doors to the open Courtyard. Area affected for refurbishment 444m 2 S203 WRC Upgrade of Trent V4.0 28

Figure 12 Trent Option 3 S203 WRC Upgrade of Trent V4.0 29