Good news stories

Complex Case and Recovery Management (CCaRM) Service Delivery Framework

The complex case and recovery management (CCARM) framework was developed by a group of clinicians from Mersey Care, Whalley. The CCARM is a service platform that aims to assist clinical teams with the development of consistent, valued outcomes through collaborating both with service users and a wider constituency of stakeholders also known as the service delivery network. Valued outcomes are, principally, ‘what matters to the service user’, but allows other matters to be important too. Having a service framework is also known to have its benefits for front line staff. 

Over the past ten months the CCaRM has acted as the service platform for three pilot areas within Specialist Learning Disability Services Division and as a framework it has set out the key sets of relationships that matter to patients, whilst it has also given shape to the sets of practices concerned with co-creating valued outcomes within Newton and Slaidburn Low Secure Unit, 3 Woodview Medium Secure Unit and the STAR Unit Assessment and Treatment Unit. 

After ten months of piloting the CCaRM, it has been recently agreed by the senior leadership team in the division to roll out the framework across the division due to there being excellent work produced by staff and service users which have resulted in further enhancing clinical outcomes.

For example: over the course of the pilot there were inspections from two independent agencies, the CQC Mental Health Act inspection of the STAR unit and the Royal College of Psychiatrist secure service peer review of 3 Woodview. The feedback was great to hear and very pleasing that the Royal College inspection team asked for more information about CCaRM. One inspector said: “Each patient had a one-page profile, health passport, communication passport and positive behavioural support plan in place. They also had their own file which contained easy read information about their treatment and care.” In addition the Mental Health Act review specifically named the CCaRM and stated the care plans were outstanding at the STAR unit.

The CCaRM has recently been presented at the 18th International Learning Disability and Offender conference where it was shared with national and international colleagues. Several organisations including St Andrews, Lancashire Care, Cheshire and Wirral Partnership, Child and Adolescent Mental Health services and social care providers have shown interest in using the CCaRM within their services having understood the impact the framework is having as a service platform for complex case management. Discussions are also in progress regarding business development opportunities.

 

Service user story

A lady was admitted to Newton and Slaidburn low secure service in August 2019, where she presented with significant self-injurious behaviour, and was very unwell. Newton and Slaidburn utilised the CCaRM to help frame individualised care whilst also working in collaboration with the service user and her family to address trauma issues that she required support with to understand.

A trauma informed care plan was developed collaboratively and was shared with all staff supporting her which resulted in no use of physical intervention and reduction of serious self-injurious behaviour which she, for many years, has ‘struggled to cope with’ (her words). The service user said that there has been no service that has looked after her that has been able to help her, she said that her current team help her, they know what to do to support her and they can help her to cope. As a result, recovery improved and continues to progress at pace and contact with family which was once fragile has been reinstated. She is very excited, and has hope for the future. By mobilising the support network and working in collaboration with the people we support what we already do well is even further enhanced.

Francesca Cairns, Specialist Learning Disability Services Division


The Community Services Division Medicines Management Team consists of pharmacists and pharmacy technicians who work closely with GPs and local health providers to help get the best out of medicines for local people. 

The team uses its experience and knowledge of medicines to ensure that patients within Liverpool get the medicines they need to effectively manage their condition. We support Liverpool Clinical Commissioning Group, Liverpool GP practices and Mersey Care to improve the health of the population by optimising the use of medicines through:

  • Structured medication review in GP practices, community care teams and care homes
  • Promoting the safe, evidence based and cost-effective use of medicines. In 2018/19 supported the CCG to implement the Direct Patient Ordering System saving nearly £1 million
  • Completing citywide safety audits including high dose opioids and DOACs in 2018/19
  • Providing up to date, unbiased information about medicines, treatments and care pathways to practitioners and service users to make the best use of medicines
  • Minimising the harm caused by medicines and support patient safety by reviewing all medicines related errors and near misses
  • Support the development of local guidelines and care pathways to optimise the management of conditions
  • Collaborating with local hospital trusts and other healthcare providers within the organisation to support these aims 
  • Support local care homes with audit and advice on medicines safety for their residents as well as being an active part of the care home multidisciplinary teams
  • Providing intensive support to GP practices who struggle with repeat prescribing systems
  • Ensure timely access to medicines and dressings for service users that are cared for by Mersey Care staff
  • Support to citywide consultant led falls service at Broadgreen hospital
  • Providing winter pressure initiatives including weekend working with community matrons and a COPD rescue pack service offered to all GP practices
  • Managing Trustwide patient group directions – 55 updated in 2018/19.

In 2018/19 over 9,000 medication reviews were completed and over 30,000 interventions for changes to medication, monitoring or referral to another service. This improves patient safety as we often stop medicines that are no longer needed or that put the patient at risk of side effects. £800,000 savings were made through reduction in waste or prescribing more cost effective choices.

Karen Wallace, Medicines Management (community)


Zero suicide

Approximately 90% of our former Liverpool Community Health colleagues have this year completed the Level 1 Suicide Awareness training which is a fantastic achievement. This means that nearly all staff in the organisation have the ability to identify key risk factors associated with suicide and are able to have a conversation with individuals feeling suicidal.

Our inpatient services in Local Services Division have made remarkable progress in working with their service users to develop individual safety plans. Individual safety plans are seen as a key intervention in our zero suicide programme and are already reducing readmissions of some of our most vulnerable service users.

The reducing self-harm project this year consolidated earlier efforts and continued to see a sustained reduction in levels of self-harm in the wards we engaged with. Work across Local Services Division this year saw the roll out of agreed interventions across a second cohort of wards and work continues to ensure teams are supported to sustain the fantastic progress.

Innovation

Our Centre for Perfect Care innovation team have been involved in everything this year from working with small teams to multi million pound European Regional Development Funded projects. The highlight perhaps being the development of augmented reality products to improve our patient experience and also to provide a greater insight into the services we provide for families and carers. This will be developed further next year.

Research

The research team this year excelled themselves in the digital arena with projects relating to the development of a new suicide prevention mobile phone app, using smart meter technology to determine whether changes in patterns of electrical appliance usage are linked to progression of cognitive decline in patients with dementia, and the use of state-of-the-art machine learning and object detection to grade and report on the characteristics of each stage of a pressure ulcer.

This is on top of increased research participation across the Trust and 100% compliance with the Comprehensive Research Networks standards for participation within 30 days and 100% of studies achieving or surpassing predicted recruitment targets.

Evidence services

Regionally across the North West there was a 7% decrease in the use of OpenAthens. This decrease was greatest in the mental health sector with some trusts declining by around a third.

Mersey Care defied regional and specialist trends increasing our online usage by 53% over this period from 6,577 sessions to 10,080 sessions.

This total is greater than the best years of Mersey Care, and the former Calderstones and Liverpool Community Health Trusts combined and is the highest in any mental health trust in the region.

Physician associates

We have developed a toolkit for physician associates in mental health settings for Health Education England and Royal College of Psychiatrists with Sheffield Trust. On the back of this, HEE requested a talking heads video on physician associates which will be completed this month.

We have contributed to an interview in Guardian May supplement on mental health on behalf of RCPsych to explain the role of physician associates in a mental health setting. This is pioneering work completed at a national level based on our local initiative. The best thing is we have done it without any formal role in HEE or RCPsych.

Reducing restrictive practice

The Trust’s commitment to reducing restrictive practices once again received national recognition as its No Force First programme secured the Health Service Journal Value Award in the Communication category. The judges were especially impressed by the co-produced nature of education for staff around the core components of the change programme: “Our winners tonight impressed the judges with their extremely compelling and moving presentation. The project shows strong evidence of staff and patients working together to achieve meaningful change for mutual benefits.”

The Trust has continually emphasised the enhanced benefits for staff of a less restrictive and less coercive approach to supporting people in distress in our inpatient environments. This year we have seen that message start to generate some international traction. In June our staff will present to staff at the German Healthcare Union (VERDI) to describe the exciting implications of a least restrictive culture for staff safety.

The Centre for Perfect Care Reducing Restrictive Practice Team has featured in a BBC TV Scotland ‘Breaking Point’ investigation into the inappropriate use of physical interventions in mental health care, with the Trust cited as a good practice exemplar of new approaches to supporting people in distress.

Dr Jennifer Kilcoyne, Trust Lead for Reducing Restrictive Practice, was interviewed by the national news publication, The Morning Star, as part of their series on positive stories about the NHS, with an in-depth focus on our reducing restrictive practice work.

We hosted a national event for the Positive and Safe Network in March which was attended by over 90 participants from across the country with a number of national expert speakers.

Two of the team have been consulting with the World Health Organisation for Europe to implement the Quality Rights Toolkit to reduce restraint and seclusion across Eastern Europe and Mersey Care's videos of practice are included in the pack which was developed by international experts in the field as a world resource.

No Force First has been shortlisted for the 2019 HSJ Patient Safety Awards again after being a previous winner (embargoed for a couple of days).

One of the first trusts to lead the pilot in training accreditation by the Restraint Reduction Network for the training to prevent and manage violence and aggression.

Jennifer Kilcoyne, Centre for Perfect Care


One community physical health division with the successful landing of former Liverpool Community Health and South Sefton services coming together.

  • Pressure ulcer reduction – increased reporting and fewer harms.
  • Falls reduction programme on ward 35 – now under the national average.
  • Winter planning – significant improvement on last year for the system.
  • Children’s services – above performance in the North West and rated Good overall by Care Quality Commission.
  • Specialist dental services rated Good overall by Care Quality Commission.
  • Planning and implementation of an integrated mental and physical health offer well underway.

Lee Taylor, Liverpool and South Sefton Community Services Division


Southport - ensuring hard-to-reach rough sleepers engage in drug and alcohol treatment

A nurse prescriber has started doing outreach work with the service that supports homeless people. The work has focused on one particular town centre in the district after concerns were raised about a core group of rough sleepers who were not engaged with treatment.

 

The challenge

Sefton Council is a metropolitan borough in Merseyside. Its housing support team commissions the voluntary sector group, Light for Life, to provide a range of services for homeless people. Meanwhile, the drugs and alcohol treatment service is commissioned by public health and provided by Mersey Care NHS Foundation Trust. Rough sleepers using Light for Life services are regularly referred into the drug and alcohol service, while in-reach services are provided into hostels. But during 2018 Light for Life staff began to notice there was a core group of rough sleepers in Southport, in the north of the borough, who were clearly struggling with drug and alcohol issues and were unengaged with treatment services. A spokesperson for Light for Life said: “We opened a winter night shelter for rough sleepers. Over the first weekend we engaged with 13 rough sleepers, 11 of whom appeared to have significant addiction issues which would prevent them from securing and keeping accommodation. “On weekends we see them seeking significant funds from street begging, particularly over Christmas. This was unlikely to change while their addiction issues were not being addressed.”

 

Solution

The council’s public health and housing support teams decided the solution lay in doing some integrated outreach work. The housing support team secured funding from the government’s Rough Sleepers Initiative to pay for the equivalent of a day’s work from a clinical nurse prescriber to work directly with the Light for Life outreach service. The nurse started accompanying the homeless service on its rounds in the town centre in early 2019. The funding covered the backfill for their time. The nurse carries out assessments, books clients in for appointments and has even been able to hand out anti-overdose drug treatment Naloxone. The nurse does the outreach work on a Thursday morning and then is available at a nearby clinic in the afternoon for the clients to drop-in for further advice, organise access to services and hand out any prescriptions they may need. It was clear that collaboration was going to be essential if we were going to engage this group. The two services already worked together, referring clients on for help. But we had never work side-by-side like this on the streets before.

 

Impact

The nurse prescribers have been able to engage a group of around 12 rough sleepers since the project started in January 2019. Half of them are now engaged with treatment. Nurse prescriber Lyndsey Davies said: “I approach them on the streets and just try to engage them in conversation. I can offer advice and let them know what services are available to them. I then let them know I will be in the clinic in the afternoon. They can come in and get prescriptions there and then, such as an opiate substitute medication. I can also organise admission into inpatient care if needed or organise referral on to our services.” Ms Davies said another part of her job is to liaise with the key workers of those who have become engaged with treatment. “It is quite common to find someone who engages for a while and then stops. I can provide that link and explain what the key worker wants from them. It helps to re-engage them. It is working really well so far.”

Lessons learned

Ms Davies said it is important to make sure you can provide a full range of advice and support to these clients when the outreach work is being done. “I go round with a member of staff from Light for Life. It means between us we can answer any questions the client may have – whether it is housing-related, benefits or health. “You have to take your opportunities when you have engaged with them. By working together we are able to do that.”

How is the approach being sustained?

The new arrangements have been funded for three months. Given the success we have had so far we would hope that we will be able to secure funding for it to continue. It has been an effective way of engaging these people who for one reason or another were not actively involved in treatment. There is also interest that the approach could be adopted on a wider regional level around Merseyside.

 

Specialist perinatal mental health services

The perinatal team was delighted to receive wave two monies from NHSE and has been able to expand the team to continue to deliver specialist perinatal care. We have recruited additional staff which includes a further perinatal psychiatrist, psychologist, occupational therapist, two family support workers, team secretary and have been able to offer 12 month placement for a trainee psychologist from the University of Manchester.

We have also accessed specialised and appropriate training within the team which included four members fortunate enough to be able to attend the the bi-annual prestigious International Marce conference in India, September 2018. What an experience and valuable training this proved to be which was also an opportunity to network, meet fellow perinatal specialists from all over the world and gain valuable knowledge which will benefit all our “Mum’s to be”.

As a team we have been active in offering perinatal training, not only within Mersey Care but offering this to CCG and other NHS trusts. We continue to maintain strong working partnerships within maternity services and continue to be included in their in house training programme. We have had continuous positive feedback for all training sessions. We continue to support requests from training universities for day placements for students studying to gain professional health qualifications.

Referrals and patients seen and treated have increased therefore achieving agreed monthly targets as per NHSE.

Our team has received numerous compliments/thank-you cards from patients/families and carers, as well as professionals, over the last year as well as being presented with two Mersey Care Positive Achievement Awards. These included winning in the nominated category as well as Winner of Winners which the team was delighted and humbled to receive.

Each and every member of the team is dedicated and strive to improve and maintain a high quality of care which will continue with the support of Mersey Care and colleagues.

 

Addictions service

66 service users have been treated for Hepatitis C within the joint Brook Place and RLUH treatment clinic since 2018. This clinic is held weekly at Brook Place and co delivered by an addiction nurse and a hepatology nurse. By successfully treating this virus we have stopped the risk of long term health deterioration, increased mortality and transition to others.

The team at Brook Place has rolled out Take home Naloxone and overdose advice/information to clients at risk of overdose and their carers, reducing the risk of death and serious harm to clients with the most complex needs.

Brook Place was awarded ‘Best student placement’ by Liverpool John Moores University, with competition from hundreds of other placement areas. The team was very proud to be commended for its work in supporting students and learners.

Brook Place continues to demonstrate and be recognised for excellent partnership working by delivering clinics in hostels across the city. This has received positive feedback from all stakeholders following a study commissioned by Liverpool CCG.

Brook Place and Mersey Care Abacus sexual health service have worked together to develop co located clinics in Brook Place improving uptake and service user access to screening and treatment. A scoping exercise is being undertaken to look at improving access to substitute prescribing for sex workers with an addiction need, and a planned weekly session from addiction services to be held in Armistead to engage LGBT service users.

Hope Centre staff have undergone trauma informed care training which supports a new way of working in Hope Centre which will improve successful outcomes as the service is accessed by a large number of clients who have adverse life experiences. By working in a trauma informed way, distress to the client during detoxification is reduced and they feel supported and safe.

 

Liverpool North/Urgent Care

We have had a winter initiative with North West Ambulance Service to develop a mental health/NWAS response car. Early indications are very positive and response to people in mental health distress has significantly improved.

The Crisis Resolution Home Treatment Team has recently been re-established and is providing home treatment support to service users. They’re providing a single point of access for inpatient beds enabling clearer and more supportive pathways for both service users and clinical teams.

Royal Liverpool Liaison Team won team of the month – very busy services and positive recognition from the acute hospital staff.

 

Donna Robinson, Local Services Division


In March the Medicines Management Team celebrated the end of completing one full year since the opening of the new Medicines Management building on the Maghull Health Park site. This has been an eventful year with many achievements and successes within the team. The new building and the technology within has enabled the team to ensure safer supply of medicines by using a robotic dispensing system and the team is currently piloting the introduction of an automated medication packing blister card system.

The Ashworth Hospital Medicines Management Team is now also based within the new building meaning that we are able to share resources to ensure a more sustainable approach to optimising the use of medicines across the divisions.

The Medicines Management Team has subscribed to the Choice and Medication Service which can be accessed by clicking on the following link https://www.choiceandmedication.org/merseycare/

The service allows service users, carers and staff to access information regarding mental health medicines and conditions in a variety of accessible formats including translated patient information leaflets and handy charts and fact sheets.

Following a period of testing of the new JAC Electronic Prescribing and Medicines Administration (EPMA) system, the Medicines Management Team and the EPMA project team upgraded the system in use within Ashworth Hospital in February. At the end on March the system was successfully introduced at Scott Clinic, the medium secure service and in the Medicines Management Department at Maghull.

This system will continue to be developed and will be implemented across the Local Services Division to ensure the safe and accurate prescribing and the timely and appropriate supply and administration of medicines moving towards a closed loop system across all inpatient areas within the Trust over the coming months.

Anna Madigan, pharmacy technician has successfully completed the Accuracy Checking Pharmacy Technician programme and is now accredited to final accuracy check dispensed medicines. This supports the dispensary team based in the Maghull department greatly.

The team based at Maghull have started working collaboratively alongside the Liverpool and South Sefton Community Services Division Medicines Management Team and this work will continue to develop moving forward.

Sarah Rafferty, Medicines Management Team


Organisational Effectiveness and Learning 2018/19 highlights

 

Awards

  • National CIPD Winner Best Public Sector L&D Initiative 2018
  • HPMA NW Awards; Winner We Improve Our Services 2018
  • Institute of OD, Winner, Best OD Team of the Year 2019
  • Institute of OD, Winner, Best OD Practitioner of the Year 2019
  • Institute of OD, Finalist, Best OD Project of the Year 2019
  • Institute of OD, Finalist, Best Publication of the Year 2019 (for Just and Learning Culture).

Developing leadership capability:

  • Leadership competency assessment included in PACE process to support regular conversations in relation to leadership development and performance
  • Doubled capacity on leadership programmes (THRIVE and STRIVE) in response to emerging demand, providing nine cohorts in total including 100 leaders from community services within the first 100 days post acquisition
  • Correlation between leadership intervention and positive QRV outcomes
  • 200 people accessed coaching from our in house coaching pool.

 

Working with clinical divisions:

  • In addition to business as usual OE provided dedicated visible support to physical health community services and HMP Liverpool
  • We worked with senior leaders to deliver targeted, evidence-based interventions. Prioritising high risk services and supporting teams through integration and transition of services.

 

Improving staff engagement:

  • Staff Survey 2018 shows a significant increase in staff engagement for all of the clinical divisions reflecting the impact of engagement activity and targeted approach to taken
  • The Culture of Care barometer provided regular temperature check on staff experience and has been successfully implemented in three out of four clinical divisions throughout the year
  • We’ve seen a significant rise in the engagement of medical staff following a decrease in 2017. This reflects the concentrated effort in this area and the implementation of the Medical Senate as the forum for medical development and engagement.

 

Overall:

  • 2018/19 has been a year of unprecedented demand for OE interventions and support across the whole Trust and the service has continued to respond to the emerging needs of the organisation. The team has been recognised as ‘OD Team of the Year’ by the Organisational Development Institute as well as showcased at the national NHS OD Conference, bringing credibility and placing Mersey Care at the centre of the developments in this field.

 

Learning and Development highlights

Widening Participation. Pre employment and entry level work

Due to the success of our Widening Participation activity Mersey Care has exceed Health Education England national targets for pre employment work.

2018/2019 has seen unprecedented expansion of all our entry level programmes and placements within all divisions.

The team has won recognition in the HPMA awards for this work and were recognised as the L&D Team of the Year in the 2019 HR Distinction Awards.

  • L&D have designed and delivered Sector Based Work Academy (SBWA) employability programmes
  • All our entry level work match participants to all opportunities offered by Mersey Care including work experience placements, pre-employment placements and traineeships. Mersey Care also provides all the formal learning opportunities including mandatory training and the Care Certificate for all new starters.
  • L&D work with local partners to present and maximize the opportunities to support interventions and opportunities which contribute to developing and progressing our future workforce. 
  • Our work involves targeted engagement in seeking to attract and support participants to undertake entry-level vocational learning developments from the following groups of people:
    • With disabilities
    • Who are young carers
    • Looked after children
    • Assessed as not being in education, employment or training (NEETS)
    • Veterans and their families
    • School and further education career events.
  • We design and deliver effective personalised pathways to employment, for people who are not in education, training or work. Providing mentoring to people on the programme through the new role employment mentor which we designed to support the programme. This role provides extensive wrap around support for people on widening participation programmes to ensure their safety and wellbeing and to ensure they have a good experience whilst working within the Trust. This role has been fundamental to the success of our entry level programmes.
  • We will be delivering a new 18 month nurse cadet programme within Local Services Division targeting our local Black, Asian and Minority Ethnic (BAME) population. We are excited about this programme as it will bring more diversity to the band three roles and to our organisation from people that understand our population and its integrated culture.

 

Vocational centre

  • L&D lead and manage the delivery and infrastructure for the vocational education activity in line with ESFA and OFSTED regulations and aligned to Mersey Care policies and workforce plans. This includes bands one to four apprenticeships and under and postgraduate apprenticeships up to advanced clinical practice at level seven
  • A new advanced clinical practice master’s pathway was designed with Liverpool University. It is truly employer led. We worked with Liverpool University to design, develop and deliver additional modules personalised to a forensic mental health setting. This was the first of its kind in the country. We worked to address the needs of this clinical division. As a really niche area the University worked with L&D and senior practitioners in high secure services who were highly regarded for their expertise in this area.

As a main provider on the Register of Approved Providers of Training a considerable amount of work has been undertaken to improve the practice and quality of provision.

 

In 2018/19

  • In line with the new apprenticeship standards we have designed and delivered the new apprenticeship standards ensuring all pathways were truly employer led meeting the needs of our workforce along all academic levels
  • We mapped our STRIVE leadership programme to a level three team leader apprenticeship for all our aspiring managers
  • ·         We have successfully taken students to their final external exam at the end of their apprenticeship. They have commenced and passed their End Point Assessment (EPA). We are first in the country to do this and it was a particularly important achievement as students were assessed within a challenging environment for undertaking an assessment in a high secure forensic setting
  • ·         We held a series of career engagement workshops and attended careers fairs and skills shows in the region. We have developed a new role of career ambassadors who talk to prospective students and school leavers about their professional role in Mersey Care. These are our own practitioners who volunteer to do this as a result of their passion for their career choice and love of the work in Mersey Care
  • We held an apprenticeship celebration event during 2019 Apprentice Week. Managers and students attended. Awards were presented to individuals with excellent attendance, to students who had completed qualifications in health and business administration. There was also a manager’s choice award and apprentice of the year
  • The vocational centre has been successful in being reaccredited within our matrix quality mark and has been successful in all City and Guilds External Verifier Assessments. 2019 will see the first OFSTED full inspection and the team are working hard to ensure we achieve a GOOD grading
  • In line with the People Plan we designed, our Practice Education Team will be coordinating and supporting a new preceptorship programme, in collaboration with the Executive Nurse Senior Leadership Team. The programme will be available for all newly qualified registered nurses and nurse associates
  • Our Practice Educator Team will also be delivering training on clinical supervision which will also align to the new Nursing and Midwifery Council standards.

Learning and development mandatory training

  • 2018/19 has seen significant collaborative work between the L&D team and the divisions to increase mandatory training and role specific training compliance levels. The team has approached each divisions unique challenges with bespoke solutions, the impact of this approach is reflected in the increase of over 8% in compliance level for the Trust over the past 11 months
  • L&D team members are involved in all clinical division planning committees and together have targeted hard to reach groups, improved staff accessibility to eLearning, worked collaboratively with IM and workforce systems team to improve user experience
  • South Sefton and Liverpool community services in April 2018 were at 47.67% and 64.39% respectively compliance levels for their divisions. At end of February this was at 76.94% and 85.06% - the largest sustained improvement within clinical division staff
  • Mersey Care has been in the top 20 of the national league table of eLearning completions during this past financial year, this is bench marked against all UK trusts. Attaining first position in December 2018 and in four other months attaining a top 20 position.

Jo Davidson, Organisational Effectiveness Team


 

Secure Services Division achievements 2018/19

Several individuals and teams have been acknowledged through team and individual of the month. The sheer dedication and desire to provide the best care possible has been evident throughout.

Staff have been involved in incidents and on occasions have received injuries due to their involvement, but on all occasions maintained their professional standards and integrity. This achievement and personal accountability cannot be underestimated.

As a division we have seen a reduction in assaults, segregation, seclusion and the need for physical intervention. All this has been achieved with some of the most hard to reach patients within the Trust.

As a division we have embraced the Just and Learning Culture. This has seen a significant reduction in investigations and trauma to those being investigated. We take seriously Freedom to Speak Up Guardian role and have supported several individual concerns, working alongside the speak up guardian to resolve such matters.

Communication has been a key focus, in previous years staff have rightly felt that communication and information has not flowed freely. We have continued with the morning meetings across the division, have utilised roadshow events to share and discuss developments and for the past six months have produced a divisional newsletter helping information flow more freely.

 

Our services

Held a ‘Moving on’ conference in October 2018, with 35 patients from high secure services in attendance.

Patients in high secure services undertook a ‘Children in Need’ charity fund raising event in November 2018.

There has been a productive audit of SD49 (Handover standards) (HSS, MSU, LSU pre CQC and also currently ongoing).

 

Care Programme Approach

  • Led on the integration of CPA across the division
  • Worked with leads (Dennis Cullen) on assuring that CPA practice remains relevant and follows best practice
  • Maintained KPIs
  • Contributed to improving patient collaboration with a recovery focus:-
    • National outcomes group
    • National secure recovery meeting
    • Amalgamating pieces of work in practice that involve partnership (patient passport)
    • Greater involvement of patients at divisional meetings (divisional meetings all have patient involvement)
    • Addressing local practice to bring it in line with secure recovery (safe, within contemporary practice and governed)
    • Bringing strong community facing recovery practice particularly in LSU and MSU (Conversations with charitable sector around voluntary work placements for LSU AND MSU, Mersey Rivers Trust, Dutch Farm, local football teams to engage patients in life beyond secure care. A greater commitment to attending the Life Rooms with a view to focussing on skills for discharge.

Supported the service with successful CQUIN activity, this recently recognised by commissioners following the external CQUIN audit when very positive feedback was provided. In particular, the trauma informed care and increased access to physical activity (introduction of patient activity workers, working bank shifts supporting hard to reach patients to access more physical activity) were particularly noted.

Audit of care plans – introduced care plan resource document.

 

Our people

Developed the trauma informed care induction pack developed for new employees to the division. Developed collaboratively by multi professional group from high secure services, medium secure services and specialist learning disability services.

Secure services local induction: 2018/19 saw the design, development and delivery of the secure division’s new local induction programme. A true collaboration of divisional, service and multidisciplinary team working. The end result is a well designed induction week which provides a positive experience and connection with the secure division whilst giving the knowledge and skills, to enable new starters hit the ground running and settle well into their teams to deliver perfect care.

Reviewed, changed and developed the division’s induction for new staff introduced, week one and two unchanged, week three has become trauma informed care week and week four is supernumerary in work place. New starters on wards are now visited in their work place, after commencing their substantive role to check how they are ‘settling in’ and if they need any further support/guidance.

Role out of care zoning following successful pilot implementation, to support the reducing restrictive practice agenda, whilst providing opportunity for meaningful engagement with all patients every shift, and use of shift planning to support effective/efficient care delivery.

Implemented an effective delivery of START training to capture existing staff and new staff during new induction. This has resulted in 95 % of registered nurses across the division now fully trained in START.

Charge nurse development sessions relaunched across the division and away days facilitated.

 

Our resources

Recruited 76 new nursing staff into the division.

 

Our future

  • We have actively participated in student engagement sessions at universities, schools and colleges
  • Held an open day for West Lancashire College
  • Seconded 12 staff to undertake nurse associate training and seconded three staff to convert from band four assistant practitioners to registered nurses
  • Supported the development of MSc Advanced Practice Apprenticeship and recruited 17 staff from secure and specialist learning disability services to undertake the programme
  • Seconded 10 nursing assistants to undertake nurse training (five learning disability and five mental health) and a fourth cohort of band two apprentices has commenced. In addition, five seconded BSc mental health due to return at the end of April 2019 and nine nurse associates commenced in post on 1 April. Three MSc learning disability (funded training) to return in April 2019
  • The next secondment opportunity for nurse training scheduled for September 2019
  • There is planned research activity in collaboration with UCLAN (PREOM secure care) which is actioned via the Clinical Secure Practice Forum and a planned DELPHI study relating to care plan standards.

 

Other noteable achievements include:

  • The publication of the prevalence of constant supportive observations in high, medium and low secure services in BJPsychbulletin (April 2018).
  • The publication of The National Policy Template for use of Supportive Observation by the Mental Health Nurse Leaders and Directors Forum (July 2018).
  • Inclusion of the National Policy Template for use of Supportive Observation by NHS Resolution referenced as an area of good practice (Nov 2018).

 

Staff communication, development, resilience and just and learning culture

The Secure Services Division facilitated 18 away days in 2018/19. They were: ward managers from both secure and specialist learning disabilities, modern matrons from both secure and specialist learning disabilities, rehabilitation, positive intervention programme and PSS, HMP Liverpool, Ruskin ward, charge nurses, Owen ward, Shelley ward, clinical support office, Ivy ward, social care, Johnson ward, Newman ward, administration department, Gibbon ward, psychology and security supervisors.

The majority of these days had resilience/health and wellbeing included as part of the day.

The first ward manager and modern matron meetings with peers from Rampton and Broadmoor Hospitals took place. This allowed for focussed discussions on role development, patient treatment and initiatives to drive least restrictive delivery of care.

The division currently has fourteen Just and Learning Culture Ambassadors across professions and departments.

The division has focussed on development over the past twelve months, three staff attended Thrive and 26 staff attended Strive leadership programmes. (Thrive is aimed at bands 7 and 8 – most of staff in these bands in secure services have done Thrive in the past – so numbers are low as now we’re finding it’s just those newly appointed to a band 7, or those who are showing an active interest in promotion to band 7 that are coming on programme now).

16 secure division teams have accessed team coaching over the past year and 35 secure division staff have accessed one-to-one coaching over the past year. In 2018/19; six staff from secure services attended a training course to become an accredited coach. This means that we now have 13 trained coaches in secure services.

 

Reducing restrictive practice and positive interventions

The Secure Services Division has continued to make considerable progress in reducing restrictive practices during 2018/19. The following is a breakdown of the achievements achieved:

  • We continue to implement the Trust Guide for Reducing Restrictive Practice and have developed an assurance tool to enable monitoring and oversight of its implementation
  • We continue to focus on our zero approach to long term segregation. Following the commencement of our audacious goal of eliminating the use of long term segregation, from April 2017 the following has been achieved during 2018/19:
    • There has been an 11.5% reduction in cumulative hours since April 2018
    • 38% reduction from patient baseline April 2018 cohort (n=26) patients nursed in LTS (n=10) progressed.

Physical restraint continues to be a key area of focus. We have achieved 36% reduction in the use of physical restraint in comparison March 2015 to February 2016. Whilst acknowledging we have had some significant incidents over the last 12 months which have caused harm to staff, we strive to provide the correct support. It is also important to acknowledge that assaults on staff causing harm continue to fall within the Secure Services Division. We have seen a 37% reduction in assaults on staff causing harm in comparison to the previous year.

 

Personal safety service

We have co-developed with service users a new Personal Safety Training to Reduce Restrictive Practice mandatory training package which was launched in January 2019.

We were identified by the Restraint Reduction Network and NHS Health Education England to undertake a national training accreditation scheme in 2018 which is still in progress.

 

National profile

We hosted a number of organisations across England and Ireland to support them in the development and delivery of a Reducing Restrictive Practice Programme.

We have been approached by a number of organisations across health and justice in England to support them in the development and delivery of a Reducing Restrictive Practice Programme.

We provide consultancy and training for the World Health Organisation on Quality Rights and Reducing Restrictive Practice. We have provided training to the following countries: Romania, Czech Republic, Latvia and Croatia during 2019. 

 

National conference presentations

  • Restraint Reduction Network (BILD) Annual Conference 2018
  • Ensuring Adherence to the 2017 National Quality Standard for Violence and Aggression Conference 2018
  • Hosted the National Positive and Safe Event on Reducing Seclusion and Long Term Segregation 2019
  • National Positive and Safe South Event Maudsley Hospital on Reducing Seclusion and Long term Segregation 2019.

 

HMP Liverpool

The secure division commenced providing mental health care at HMP Liverpool in April 2018. The prison had been subject to several high profile audits, culminating in public scrutiny around care and treatment of prisoners and patients being held there.

The division has developed a staffing model that ensures the Trust values and strategic aims are at the forefront of patient care.

The division has embedded a Just and Learning Culture, front loading training and development for all staff.

We have a dedicated lead for quality and improvement within the prison, this role has transformed expectation and ensures that we maintain the high standards expected within the division around patient care and treatment. The quality lead continues to work alongside perfect care colleagues on zero suicide initiatives and personality disorder awareness amongst others.

The service manager has forged strong links with HMP Governors to ensure patient risks are managed accordingly.

The prison clinical model includes specialist roles which include social work, occupational therapy, psychology and talking therapies. We have introduced learning disability nurses to work alongside mental health nurses ensuring that we cater for all patient needs. These specific roles have allowed for a holistic approach to patient care, ensuring we capture patients and their relative’s views on care and treatment.

We have introduced a robust safeguarding mechanism increasing patient safety.

The above initiatives have been acknowledged in the recent CQC audit. The report was extremely positive, something HMP staff are very proud of. The CQC report has acted as a catalyst to enhance care to the next level.

The HMP Liverpool team was acknowledged at the Positive Achievement Awards ceremony and won team of the month earlier this year.

 

HMP Garth

There is within the prison meaningful service user involvement in all Beacon recruitment (both officer and clinical teams) in the form of a separate service user interview panel. Added to this we have ongoing extensive service user involvement in developing and designing a research proposal for the service.

There have been: two open days, one family day and five year anniversary event within 2018/19 both received very positive feedback.

Following the appointment of a drama therapist we have now been able to add drama therapy to the Beacon treatment programme.

The Beacon has achieved its highest ever levels of occupancy and with the current number of planned admissions expect to be fully occupied for the first time ever imminently.

The procurement of bio-feedback equipment has allowed us to progress joint research with other OPD services into the benefits of adding this additional therapy to the Beacon programme.

We have commenced work on updating the Beacon DVD which will feature both service users and staff sharing their experiences for the benefit of others. We have commissioned further music based therapies from two external providers - both of which have been very positively received by our service users in the past.

 

The primary health care team for secure services

The team has improved physical health care. Diabetes and chronic disease management - Laura Clark, dietitian and Jenny Saunders, chronic disease nurse, teamed up to work collaboratively across the secure service. They set up specialist weight management and diabetes/pre-diabetes clinics.

They aim to see patients every two weeks, they have developed an education programme which they deliver to patients across the Trust. It was developed as a result of a consultation with the diabetic specialist nurses in the community. We are currently taking it through the accreditation process with Quismet in order that our patients can be assured of quality and parity of service. There has been improvements in health markers of patients which can be seen in the data gathered.

They have developed workbooks for patients to support their education and it can be accessed in easy read format for patients with learning disabilities.

Obesity strategy - Laura Clark drives this forward tackling this with her MDT including: ward staff, health and fitness team, least restrictive practice, health centre staff and psychology. It's a huge task and although daunting, good innovative practice is being looked at and developed for the benefit of our patients to improve their physical health and co-morbidity risk.

The FITTER programme is an exercise and nutrition based eight week programme for patients. It is proving very popular and was developed with Carstairs - sharing good practice at its best.

While this innovative and courageous practice is going on we need the day to day running of the health centre to continue and carry on the good work already embedded into practice. Our HCA members of staff are key to the smooth running of our services and their work is greatly appreciated. We lead by example and aim to be good role models for our patients. We have a constructive leadership team who encourage us to be forward thinking, conscientious, passionate and supportive of each other and our wider MDT.

Patient physical health is now being taken much more seriously by the Trust and this is reflected in the change of attitude amongst staff and patients. Clinics are rarely empty and there are plenty of examples of good practice. The innovative work being done can only happen if you have good consistent staff getting the basics right.

 

Security departmental achievements

The Director of Security received a national award for Security Innovation from the National Association of Healthcare Security.

High secure services received ‘Green’ substantial (highest) rating in the national peer audit regarding compliance with the NHS Safety and Security Directions (2013). The division’s security department at Ashworth Hospital led on producing a revised audit tool that was accepted as the tool that is now used during the peer audits.

Security training compliance levels throughout secure services continue to improve: high 87.89%, medium 96.06%, low 84.75%. Security training is now established in Whalley and is being delivered to over 200 staff.

 

Departmental CPD

The clinical liaison nurses - security and control centre managers have attended the Trust’s Strive and Thrive Leadership, Coaching and Challenging Conversations Courses. Projects included an updating and reintroducing an audit programme for monitoring the wards’ compliance with WBS procedures providing security and clinical managers with assurance that basic security is embedded.

The team has embraced the peer audit model and dedicated additional time and commitment to undertaking this process at our sister hospital, whilst maintaining our own high standards.

Security training manager achieved level 7 diploma in Strategic Management and Leadership and the security trainers received Level 4 Diploma in Learning and Development (Management) and a Level 3 Award in Education and Training. Collectively the team have achieved a Level 3 award in Continuing Professional Development/Metal Detecting Portals/Bag Searching/Hand Held Detectors/Body Searches/Room Searches, Level 2 award in Dealing with Suspect Packages and Level 3 B-Tec in Handcuff and Soft-Cuff Instructor Accreditation. They also received notable thanks from the Learning and Development Apprenticeship Team for being very supportive towards their learners as well as supporting the Trust with their pre-employment programme and providing students the opportunity to work with the team.

 

Specialist learning disability service

The security department appointed a dedicated security manager and established a security committee. Sought funding and appointed site security and dedicated police officer and collaboratively reviewed and improved aspects of physical security at the Whalley site and security intelligence reports are established and imbedded.

 

Social care

The last 12 months saw the incorporation of social work into HMP Liverpool providing patients with: short interventions around social issues, social histories, taking a lead on safeguarding, triaging safeguarding issues, contributing to the MDT, a social perspective, and acting as a link for families.

There have been transitional changes to social care management structure which anticipates the integration of secure and specialist learning disability divisions.

Successful and well attended social care leaders’ away day which helped forge divisional links. 

The elimination of paper social work records in high secure services has been successfully implemented.

Participation in the Think Ahead programme, which also saw MP Simon Twigg visit the programme. This new route into social work for graduates and career changers has been well received.

Commenced the supervising social workers in training Mersey Care have working in partnership with other stakeholders shaping the programme.

Forensic social workers presented at World Social Work Day.

We have overseen by the equality and human rights task group George Sullivan awarded Jane Roden memorial award from the CPS for work around promoting equality for the LGBTI and promoting the work of the Merseyside and Cheshire Navajo Partnership. 

BAME/LGBT staff obtained professional coaching certificates.

Interfaith team and spirituality/equality annual PEACE service held in both Ashworth Hospital and Scott Clinic.

Security updates - introduction of awareness of transgender issues onto security induction (supporting patients and staff ).

Security processes amended - search policy amended to take account of Transgender patients.

Forensic LGBT focus group set up - professional to look at issues that impact upon service delivery for LGBT patients.

 

High secure services psychology

Clinical

High secure psychological services have worked to reduce the waiting times for referrals to engagement in therapy. Although not a KPI for the service, the service endeavours to ensure that no patient is waiting for longer than 18 weeks for therapy.

69 patients engaged in formal face to face psychological therapies in the last 12 months, and 30 admission assessments were competed. This accounts for 96 patients (42%) engaging in direct face to face and regular specialist interventions and assessments.

The service has also led on the implementation of the Barriers to Change Checklist (BCC) from the HOPES model which aims to address the key barriers associated with long term segregation. The BCC is now routine business on the six high dependency wards and is audited on a regular basis to review compliance.

 

Conference presentations

Our staff have presented at various conferences nationally and internationally drawing upon the breadth of clinical knowledge and experience available within high secure services.

 

Teaching

Our staff hold visiting lectureships at a number of universities across the country on doctoral clinical psychology training courses, forensic psychology and post graduate training courses in clinical neuropsychology.

 

Trainee placements

High secure psychological services provides high quality and much sought after training placements to trainee clinical psychologists, trainee forensic psychologists from the UK and overseas.

We have well established links with the North West clinical psychology training courses covering the Universities of Manchester, Liverpool, and Lancaster and soon to include University of Bangor and Stafford.

We have a well established internship programme with the University Of Maastricht and provide six and nine month clinical placements for between three and four trainees each year. The placements are much sought after and trainee feedback is very positive. Trainees also undertake research as part of their placements, facilitated by the University of Central Lancashire.

The service also provided honorary clinical placements for trainees who are engaged in research through the Ashworth Research Centre. These placements provide an avenue for forensic psychologists to gain experience within a mental health setting.

Staff development

The service is committed to having staff that have the most up to date skills and has recently invested in training to ensure that all staff have access to NICE approved treatment for addressing the trauma related difficulties that underpins much of the offending behaviour of our patients. The service has made EMDR training available to staff from across the Secure and Specialist Learning Disability Services Divisions.

The service also supports staff in gaining specialist psychological therapy accreditation, a number of staff have been successful.

 

Publication of relevant research and articles assist in developing and raising the profile of the psychology department.

Mersey forensic psychology service

We launched the new trauma focused therapy service into North West prisons. This is an innovative service, not available in other prisons, that aims to reduce risk of serious violent and sexual offending by addressing the impact of childhood trauma on current functioning. It will help the progress of challenging and complex individuals for whom standard prison interventions have not been effective and are not progressing through the rehabilitation system.

The new prevention service was featured in Liverpool Echo, leading to praise and support from primary care, charity and GP services across Merseyside and an increase in referrals for men who are struggling or concerned about their unhealthy sexual feelings. The service aims to prevent sexual abuse by working with people before they are at the point of offending.

A chapter describing the work at MFPS, written by Dr Simon Duff, Dr Lorraine Perry and Dr Lisa Wright, was published in the book ‘Sexual Crime and Prevention’.

Steve Newton, Secure Services Division


Reducing restrictive practice

Maplewood 3 low secure unit was selected to take part in a national Quality Improvement project by the Royal College of Psychiatry to reduce restraint and seclusion over a two year period. The project group meets every two weeks and has been attending monthly events in London as part of this project.

As of October 2018, the theoretical aspect of the personal safety training at Whalley is now co-facilitated by service users who share their lived experiences. 

Staff and service users at Whalley have co-produced a DVD about their experiences of seclusion and long term segregation. This has been presented at national conferences and has received positive feedback.

Two teams on Woodview medium secure unit have progressed two service users out of long term segregation. The service users have made progress in their care pathways; one has had a successful transfer to low secure and one has been accepted for low secure and has been on a home visit for the first time in 11 years.

Introduction of the Safety Pod on wards at SpLDD has seen a reduction of floor restraints with a number of service users. For one service user we have seen a 51% reduction in T-supine restraints with further reduction anticipated for this month. The service is looking at introducing the Safety Pod for all areas for 2019/20.

The women’s low secure service introduced morning multi-disciplinary team huddles in July 2018. Following the introduction of this, the team on Coniston and Grasmere low secure unit saw a period of three months with zero restraint and zero seclusion. 

The Dynamic Appraisal of Situational Aggression (DASA) has been introduced in to two clinical areas at Whalley. The team at 1 Woodview has created a spreadsheet for DASA to create accessible graphs for both staff and service users to use to highlight any patterns in escalation of aggression. This has allowed them to put in proactive measures and reduce incidents of violence and restraint for individuals.

The teams on Woodview have introduced ‘breakfast club’ meetings where staff who have worked a night shift and staff who are working a day shift come together for reflective practice sessions and breakfast together. Teams regularly share formulations and where possible, service users have been invited to co-facilitate these sessions. Teams have described how this has helped them to reduce restrictions including restraint and seclusion.

The staff team on 3 Woodview has begun to develop co-produced, individualised seclusion care plans which are centred on individual psychological formulations and meaningful activities. This has reduced the frequency and the length of time in seclusion. For one service user in particular, the duration has reduced from 23 days (max) to one day (max); this service user has now been accepted for low secure services. This initiative is now being shared across the division.

Service users ‘Making a Difference: No Force First’ group development of easy read resources and reaching out to the wards to develop new ideas including a ‘welcome box’ for new admissions into secure services.


Social Partnership Award HPMA June 2018 for our partnership work in developing a Just and Learning Culture. Also written up in the national Chartered Institute of Professional Development people magazine, NHS Improvement toolkit, Hospital Management magazine, Unison magazine and Care Quality Commission website as best practice. 

HPMA June 2018 - HR Director of the Year. 

Best Learning and Development Initiative (public sector) September 2018 for the development of our outreach programme working with Department of Trade and Industry and Job Centre Plus to bring people from unemployment into work.

Workforce well being award. October 2018 - Positive Practice in Mental Health for initiatives around staff health and wellbeing. 

Organisational Design team of the year March 2019.

Institute of Organisational Development awards for inspirational work around OD interventions such as team development, leadership programmes, maximising potential workstreams. 

OD practitioner of the year - Jo Davidson, March 2019 

Institute of Organisational Development awards for leading all of the above. 

Amanda Oates, Director of Workforce