Music at Cedar House

Until very recently Cedar House patients had to travel to Canterbury to indulge their passion for music. However, earlier this year, the hospital decided to invest in our own music capabilities to enable more patients to take part, more often.

Cedar House now boasts its own music room in a dedicated building with a range of instruments; drums, keyboards, guitars, bongos and even DJ decks. We also have our own music lead, professional musician, Douglas Mukuze, who ensures that patients can progress and develop their musical abilities.

There are ten patients who play as regularly as possible, all of whom have been taught from scratch. For patients with intellectual disabilities, many of whom may have had negative experiences in formal learning environments, learning an instrument can seem quite a challenge. However, having worked with us as a support worker previously, Douglas has an in-depth understanding of our patients and their needs. He usually teaches them to play ‘by ear’ and the results are astounding. Sometimes he will simply accompany patients, for example, he plays keyboard whilst one of the patients plays drums. Sometimes patients play covers, other times their own compositions. It is completely their choice.

The therapeutic effect of music in terms of mood, behaviours and general positivity are well known. For our patients, some of whom have some quite challenging behaviours, the opportunity to simply come and bang on drums can help elevate mood and moderate behaviour. For those who are passionate about music, we’re really proud that we’re able to create an environment where they can pursue that passion.  Above all, we look forward to seeing them progress and perform at the many events at Cedar House.

 


Huntercombe Stafford rated “outstanding” for being caring

Huntercombe Hospital Stafford has been rated as outstanding for being caring by the Care Quality Commission. In an inspection report published on 29th October 2018, the CQC rated the hospital as “good” overall and “good” against the core inspection themes of being safe, providing an effective service, being responsive to patients’ needs and well-led.

Patients told the CQC inspectors that they were happy and safe; they were satisfied they were getting the right support for their problems and had seen progress in themselves. They said they would recommend other people to be treated at the hospital.

Our hospital, at Ivetsey Bank, Wheaton Aston provides mental health services for young people aged twelve to eighteen, including some patients who have been detained under provisions of the Mental Health Act. It comprises three wards. One is a psychiatric intensive care unit; the second is an assessment unit treating young people with a range of diagnoses from psychosis and bipolar disorder to depression; the third specialises in eating disorder.

The CQC inspectors reported that patients spoke highly of the support they received from the hospital team who, they said, understood their individual needs and were compassionate and always willing to offer emotional and practical support.

The patients and their families said they were treated with dignity and respect.

Valerie Michie, Chief Executive of The Huntercombe Group said: ”Such a good CQC inspection report recognises the progress that has been achieved by the dedicated multi-disciplinary team who have worked so  well together to provide compassionate and effective care and treatment for their patients. It is particularly gratifying to see the positive comments from the patients themselves and their relatives.”

The inspectors found that there were enough staff with the right qualifications and skills mix to meet the patients’ needs and patients were able to have regular one-to-one time with their named nurse.

The inspectors saw that every patient had an up to date, personalised, holistic care plan and there were effective systems in place to monitor and review patients’ progress.

The hospital demonstrated high commitment to develop its service with the full participation of patients and the team actively involved them in preparing their care plans and in decisions around their care and treatment. Relationships between the team and patients were positive and empowered them to take ownership of their care. Patients views were also valued on wider aspects of how the hospital was run day to day.

Patients had good access to physical healthcare specialists and a wide range of therapeutic activities.

The multi-disciplinary team managed risks to patients well. They made a comprehensive individual risk assessment for every patient and reviewed this regularly and updated it when required. They also carried out regular environmental risk assessments to ensure the hospital is a safe place.

All patients had a positive behavioural support plan. These plans identified how the care team would engage with patients and support them to encourage positive behaviours, while being alert to early warning signs of unexpected behaviour. The team were trained in methods of safe de-escalation without physical restraint. They had taken positive steps to reduce blanket restrictions as far as they could and any restrictions on patients were proportionate to the level of risk posed. Patients had access to mobile phones, internet, iPads and freedom to enter unlocked rooms.

The team tailored one-to-one engagement, leisure activities, and support to develop social and independent living skills to address the individual needs of each patient.

The members of the hospital team overwhelmingly reported high levels of satisfaction including those on contract from agency. They all felt respected, supported to do their jobs and valued. The leaders showed the high levels of experience and ability needed to provide high quality care.

 


Reasons to stay: Huntercombe’s Nurse Leadership Programme

The current nurse-recruitment crisis in the UK is a matter of record. The particular demands of working in mental health make recruiting nurses for this specialist field even more challenging.

Healthcare organisations in the public and private sectors have responded by launching initiatives to develop their own nursing pools through alternative channels of education and training (see the ‘Grow your own nurses’ article on this site).

The problem, though, goes beyond persuading nursing candidates to commit to a career in healthcare. They also need to have good reasons for staying in the profession. The reality is that a growing number of qualified nurses in the UK are jumping ship.

According to a recent report by the House of Commons Health Committee, around 29,000 UK nurses and midwives left the profession in 2016-17, up from just under 21,000 in 2012-13, with many citing difficult working conditions or saying they felt undervalued[1].

Recruitment not retention

As the Committee pointed out, most government policy has focused on boosting the intake of new nurses, rather than working to retain existing nurses. Its report also highlighted reductions in available funding for nurses’ continuing professional development (CPD), which has shrunk from £205 million to £84 million in just two years.

It has been argued that mature students are more likely to stay in nursing. Here, though, the impact of a slump in applications for undergraduate nursing courses is especially pronounced.

Data from the Universities and Colleges Admissions Service (UCAS) show that in 2017, 4,575 applicants aged 21 to 25 years were accepted onto university nursing courses, a drop of 13 per cent on 2016, while the number of applicants aged 26 years and over (8,450) fell by 6.0 per cent year on year[2].

This is particularly worrying given that mature students make up a relatively high proportion of students in areas where nurse shortages are particularly marked, such as mental health and learning disabilities.

Career path

One way to give nurses, in mental health or anywhere else, a sense of purpose and value that encourages them to stick with their profession is by offering them a meaningful and compelling career path.

At The Huntercombe Group (THG) we have addressed this need through our RCN Nurse Leadership Programme, which is now entering its fourth year. The programme is supported by the Royal College of Nursing (RCN) and receives about 40 applications (for around 18 places) a year from nurses working for THG who are either already in senior roles, or who have been identified as senior or charge nurses of the future.

The Nurse Leadership Programme includes a four-day residential course geared to developing self-awareness, followed by peer-supported action learning and a work-based project that participants present to the organisational board and others at a Huntercombe Group Nurse Leadership conference. Around 50 nurse leaders have been through the programme to date.

Some of the work-based projects developed as part of the programme are taken forward within THG, to general benefit. These projects do not necessarily have to be clinical. One such example was a project that challenged the business on its maternity benefits for nurses, resulting in a change in maternity policy across the group.

Making great leaders

Essentially, the Nurse Leadership Programme is about making great leaders out of nurses who might otherwise have transitioned to managerial roles without any specialised training.

People who have strong vocational skills are not always equipped with the skills they need for leadership, nor may they want to be. Nurses need a particular set of skills and behavioural traits to manage other nurses or support workers.

This also comes back to making sure that nurse retention is firmly embedded as a strategy across The Huntercombe Group. Where nursing staff are properly trained in key roles, attrition can be reduced – and indeed has been. In 2017, nurse attrition at THG was down by 19% against the previous year.

The best leaders are not only more committed to the organisation they serve. They also inspire others within that organisation to stay the course, maximise their abilities, take responsibility and pursue leadership opportunities themselves.

Nurse retention is a tough proposition for any healthcare organisation, and in the mental-health sector it presents special difficulties. Our RCN Nurse Leadership Programme is not the whole solution but it goes a long way towards convincing mental-health nurses they are on the right career path within The Huntercombe Group.

For more information visit our Recruitment pages

[1] The nursing workforce. House of Commons Health Committee. Second Report of Session 2017–19. 26 January 2018. Retrieved from https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/353/353.pdf.
[2] The nursing workforce. House of Commons Health Committee. Second Report of Session 2017–19. 26 January 2018. Retrieved from https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/353/353.pdf

Mersea Island Festival – enabling Cedar house patients to shine

The Mersea Island Festival takes place over the August bank holiday every year and brings together young people and adults with or without a physical or learning disability. The Festival provides an opportunity for attendees to try out new activities, make new friends, challenge themselves, build their self-confidence and independence – and have loads of fun.

The Cedar House team have been taking patients to the Festival for the past five years and are huge advocates of all that it does for our patients. Historically we’ve only taken a small group of around three patients but this year we were able to take six patients (and four staff).

For our patients, some of whom may have been hospitalised for many years, the Festival may be the closest they’ve come to a holiday in many years so prompts great excitement; as well as all of the advertised activities, patients are surprised by how much freedom they’re given – the environment is nothing like that which they are used to in hospital.

There is a real ‘no limits’ approach at the festival, with attendees encouraged to try whatever they would like to. Whilst all of our attending patients are ambulant we’ve seen patients in wheelchairs hoisted up to experience the feeling of abseiling and attendees participating in activities which elsewhere would simply not have been considered an option.

The benefits to our patients are huge, they get a chance to find out what they’re capable of and what their abilities are outside of a hospital setting.  For many this is a brand new experience where they have the opportunity to mix with lots of other people with similar circumstances to their own.

Some of our patients are not big conversationalists so don’t always articulate what it is that they gain from attending the festival, but we can see it. They return with a confidence that they didn’t have before and they seem to ‘shine’ just that little bit more.

And this is isn’t just a ‘one off’, two of the patients attending this year have been before and one patient has attended three times. Not surprisingly, there is a great appetite amongst patients to be able to attend the festival and for those who are assessed as potentially able to attend, this is a great goal to work towards. It facilitates the re-enforcing of a boundaries and rewards structure that drives better behaviour.

We’re really proud of our patients who attend the Festival. Most other attendees, whilst living with similar conditions to many of our patients, are not from the same type of hospital as Cedar Lodge. The fact that we’re able to safely attend with our patients is testament to the progress they make whilst in our care and our focus on equipping patients with skills they will need for discharge.

Sometimes, a little trust goes a long long way.

 


Growing your own Mental Health Nurses

Managing mental health issues and learning disabilities requires multidisciplinary input, and nurses are an invaluable part of that team.

They are at the front line of delivering strategies to address challenging behaviour and help inpatients towards fulfilled, integrated lives back in the community.  Mental-health nurses also provide the day-to-day support and interaction that are crucial facets of relationship-building and facilitating a return to stability.

Yet recruitment and retention of mental-health nurses are hampered by the broader crisis affecting nursing supply nationwide – and to an even larger extent, given the particular demands of working in the sector.

Shortfalls in the nursing workforce

Estimates of current shortfalls in the nursing workforce vary, but they are substantial. According to a report by the House of Commons Health Committee[1], there are anything between 36,000 and 40,000 nursing vacancies in NHS England alone, with Health Education England (HEE) estimating that 33,000 of the 36,000 nursing vacancies in the National Health Service are filled by bank or agency staff.

The report also noted that vacancy rates vary between specialities: nursing for learning disabilities has the highest vacancy rate, at 16.3% within NHS England, followed by mental-health nursing at 14.3%. A recent briefing paper by HEE and the NHS Confederation highlighted a 13 per cent reduction in full-time equivalent mental health nurses working for the NHS between September 2009 and August 2017[2].

These challenges can be all the more daunting for companies providing specialised services to the NHS. They benefit only tangentially from new government initiatives such as ‘golden hello’ incentive payments for postgraduate nursing students taking up NHS positions[3], overseas recruitment to fill short- to medium-term staffing gaps[4], or the 21,000 new posts promised by 2021 under the government’s plans to expand the NHS mental-health workforce[5].

Thin on the ground

There are numerous reasons why nurses, and mental health nurses in particular, are so thin on the ground. A common complaint is that the withdrawal of the bursary scheme for nursing students is behind the significant drop in applications to undergraduate nursing courses across England: down by 23% in 2017/18 compared with 2016/17.

This means prospective nurses now have take out a student loan or rely on existing employers embracing alternative routes such as nursing-associate training or nurse-degree apprenticeships. Tuition fees for universities in England now cost £9,250 a year. Once maintenance loans are factored in, the average debt at graduation is estimated at £50,000 or £56,000 for students from less well-off backgrounds[6].

Bursaries are not the whole story, though. As the Commons Health Committee pointed out, the number of nurse training places was capped under the bursary scheme, while the number of applications for university courses exceeded the number of places available by two to one[7].

There are further complications, such as limited capacity for clinical placements on degree courses, the UK’s decision to leave the European Union alongside more stringent requirements for language training, or lower numbers of mature students pursuing a university degree in nursing.

A tough job

A more fundamental problem, and one with particular relevance to mental healthcare, is that nursing is a tough job requiring considerable physical, emotional and psychological resilience.

Healthcare services are under constant pressure from escalating demand and limited funding, while patients and their conditions become ever more complex, especially in specialised services. In a culture more oriented to self-absorption and personal gain, the traditional notions of public service that have sustained professions such as nursing are in retreat.

Once again, the shortfall is particularly marked in mental health. According to the Health Committee report, some universities that offer undergraduate courses in mental health and learning disability nursing are struggling to recruit enough students[8].

Grow our own nurses scheme

There are no easy or quick solutions to these problems. However, a number of provider organisations, both within and outside the NHS, are grasping the nettle by launching ‘Grow your own nurses’ programmes to nurture their own talent.

One crucial barrier to graduate entry in mental health or other forms of nursing is the prospect of running up significant debts while effectively putting earnings on hold. With The Huntercombe Group’s (THG) Grow your own nurses scheme, participants can continue working while training as nurses all the way up to graduate level.

THG started taking a closer look at its nurse recruitment and retention needs around two-and-a-half years ago. The resulting Grow your own programme starts with a 12-month Open University course called the Higher Education Certificate in Healthcare Practice.

This is the equivalent of taking the first year of a BSc (hons) degree in Adult or Mental Health Nursing. Staff members who successfully complete the 12-month course are then invited to apply for the second stage of this programme which will, if successfully completed, deliver a Nursing Degree.

The partnership with the Open University gives participants a good deal of flexibility in balancing their commitments. Huntercombe staff usually spend 50% of their time as students and the other 50% at work.

One obstacle we encountered, though, was finding our staff practice placements in NHS Trusts for their second year: a Nursing Degree requires experience in all areas of the profession. These places are usually reserved for students coming to work in the NHS.

We have resolved this issue by seconding participants out to study at local universities, which then organise the necessary practice placements. THG continues to pay their salary while funding their education, and course participants work shifts whenever they can. They are guaranteed a nurse’s role at THG once qualified.

Cohort of trainee nurses

At the moment we have three staff at our Cedar House facility still working with the Open University, while four staff at Eldertree Lodge are on the local university pathway.

We also have another cohort looking for placements from September this year. Moreover, Cedar House is piloting a nurse-associate programme with the local university in Kent, where five students will start training.

Support workers and healthcare assistants

The aim is to have a fresh cohort of THG trainees every year and a pipeline of qualified nurses coming through the business.

Support workers are at the heart of this process. In the past we have benefited from highly capable support workers at Huntercombe who nonetheless could not afford to train as nurses.

By funding participation in the Grow your own nurses scheme, we are not only opening up a new career path for support workers but cultivating engaged, informed and loyal employees who understand the complexities and challenges of mental health. Graduate nurses from universities often need substantial in-house training to adapt to the very specific demands of our services.

Support workers or healthcare assistants can be a severely undervalued part of the mental health equation, too often overlooked in policymaking or perceived as unregulated and poorly trained.

Yet they are intrinsic to helping patients manage their life on a daily basis, providing anything from physical care and support at mealtimes through to one-to-one conversation and interaction or encouragement to engage with therapy.

Flexible programme to qualify as a mental health nurse

The flexibility of the Grow your own nurses scheme means staff can take a break from their educational commitments if necessary and pick up the course when they have more time. Moreover, the scheme provides an inclusive entry route; staff who at the start of their career were not able to consider nurse training or other staff who may have difficulty with academic requirements for university nursing courses now have an opportunity to develop the career they aspire to (or something like that). With its mixture of formal learning in a university environment and on-the-job experience in THG facilities, Grow your own nurses is building on the best of ground-level skills, such as compassion and behavioural insights, to produce a new generation of nursing staff.

These qualified professionals will not only fill critical recruitment gaps in mental health but will bring a more rounded and rooted perspective to an always challenging but rewarding occupation.

[1]  The nursing workforce. House of Commons Health Committee. Second Report of Session 2017–19. 26 January 2018. Retrieved from https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/353/353.pdf.
[2] Funding and staffing of NHS mental health providers: still waiting for parity. Helen Gilburt. The King’s Fund. 16 January 2018.  Retrieved from https://www.kingsfund.org.uk/publications/funding-staffing-mental-health-providers.
[3]  The Government response to the Health and Social Care Select Committee Second Report of Session 2017-19, ‘The Nursing Workforce’. July 2018. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/728096/gov-response-to-hscsc-2018-report-on-nursing-workforce.pdf.
[4] The Government response to the Health and Social Care Select Committee Second Report of Session 2017-19, ‘The Nursing Workforce’. July 2018. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/728096/gov-response-to-hscsc-2018-report-on-nursing-workforce.pdf.
[5] Thousands of new roles to be created in mental health workforce plan. Department of Health and Social Care. 31 July 2017. Retrieved from https://www.gov.uk/government/news/thousands-of-new-roles-to-be-created-in-mental-health-workforce-plan.
[6] Theresa May’s university review will not scrap fees. Sean Coughlan. BBC News. 19 February 2018. Retrieved from https://www.bbc.co.uk/news/education-43106736.
[7] The nursing workforce. House of Commons Health Committee. Second Report of Session 2017–19. 26 January 2018. Retrieved from https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/353/353.pdf.
[8] The nursing workforce. House of Commons Health Committee. Second Report of Session 2017–19. 26 January 2018. Retrieved from https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/353/353.pdf.

Cedar House Education and Therapy Department

Education plays a critical role in equipping our patients with skills for life as well as building confidence and self-esteem. From the point of admission, we are focused on the skills an individual needs to develop and how to assist them in preparing for discharge or the next stage of their journey. In order to achieve these goals the Education and Therapy department employ a qualified teacher, along with Occupational Therapists that lead a team of three technical instructors and a sports development practitioner to deliver a variety of activities.

The educational activities offered within Cedar House are broken down into two key areas, Cedar Academy and Cedar Recovery College.

Cedar Academy

Cedar Academy offers 75 sessions per week that aim to develop educational, functional and social skills through individual and group sessions.

These sessions enable us to offer a variety of courses known as ASDANs. ASDAN is a curriculum development organisation and awarding body offering programmes and qualifications that explicitly grow skills for learning, employment and life. ASDANs have been designed to allow learners of all abilities to engage and progress and Cedar Academy offers two types: Short Courses and Towards Independence.

ASDAN Short Courses allow learners to engage in extended topics that are broken into a series of challenges. The learner selects the challenges they wish to complete and are able to work with staff to plan and structure their own learning using a ‘Plan, Do, Review Sheet’. This allows learners to tailor their learning to their individual needs, plan the way they will complete the challenge and highlight which skills they wish to build upon. As learners complete challenges they are then encouraged to review their progress and reflect upon their achievements. Upon completion of an ASDAN Short Course learners are awarded a number of credits relating to the challenges completed, these credits can then be put towards qualifications awarded by ASDAN.

ASDAN Towards Independence provides a framework of activities through which personal, social and independence skills can be developed and accredited for those with severe learning difficulties (SLD) and profound multiple learning difficulties (PMLD). Towards Independence offers formal recognition for small steps of achievement towards a larger goal. Modules can be used separately and accumulated to build a record of personal achievement.

All ASDANs can be evidenced through video and photography rather than written work and courses are broken down into bite-sized chunks that can be completed over as long a period of time as necessary. All evidence is then kept in the student’s ASDAN folder that they compile to evidence their learning. For patients with conditions on the autistic spectrum the breaking down of tasks into small steps, with no time pressures, enables them to complete one step at a time without becoming overwhelmed.

Cedar Academy also includes a large variety of open group sessions designed to focus on social interaction through low pressure, entertaining group sessions requested by patients and able to be adapted to the individual levels of the patients attending. This is an important aspect of Cedar Academy as many of our patients have had poor experiences in formal education, resulting in poor confidence and a lack of desire or interest in continuing their education.

Cedar Academy works very differently to traditional education settings that they may have experienced previously and encourages a relaxed approach to education where the individual determines how long they wish to engage for and how demanding the topic may be. As patients increase their attendance there is also a notable increase in their willingness to engage for longer and to approach subjects that they find more challenging.

Evidence of patient engagement is collected through all aspects of Cedar Academy and this evidence can be used to complete elements of an ASDAN Activities and Peer Tutoring Short Course should a patient wish. To date, 31 patients have provided evidence for engagement in this course and this will allow patients who do not have the confidence or desire to complete an academically based short course to gain a number of credits that are able to be put towards further courses.

Cedar Academy has sessions available for money management, food skills, sports, arts and crafts, science, literacy and numeracy as well as more social activities such as pool competitions, patient run breakfast clubs and cafes and film clubs. Whenever a change of timetable is carried out patients are consulted with regards to the sessions they wish to see included and this allows the Academy to continue to develop a patient centred approach to its delivery.

Cedar Recovery College

Cedar Recovery College is the second aspect of the Education and Therapy Department and offers an innovative approach towards mental health recovery.

Cedar House Recovery College is the first college to be set up within the independent sector nationally to provide recovery focused education-based interventions for patients with a primary diagnosis of intellectual disability. Our Recovery College enables education-based sessions to be co-produced and co-delivered alongside people with lived experience (peer trainers). The Recovery College parameters set out that the college should deliver relevant recovery focused interventions delivered by both a clinician and a person with lived experience of mental health issues.

It is imperative that a person with lived experience of mental health issues works alongside clinicians to develop the relevant recovery-based programmes, to ensure that a patient-centred approach remains the dominant theme within the college; this can best be achieved by them acquiring a central role in the development and delivery of the college curriculum.

By working closely with NHS England and an expert advisor Nash Momori, we have developed a Recovery College specifically tailored to the needs of patients at Cedar House. Patients were eager to put themselves forward for the Recovery College Peer Training course, where four originally qualified as Peer Trainers; this has since increased to 6 as other patients look to the Peer Trainer title as a means of furthering themselves within the hospital and giving them a greater feeling of role validation. The Peer Trainers benefit from the range of skills they develop through the co-production and co-delivery of the training, which in turn aids them on their own recovery journey.

The Recovery College is still developing, but it has already shown to have a positive impact on the lives of several patients and this impact will only increase as the Recovery College continues.

Impact on Patients 

One of our great success stories is that of a patient who undertook a Sport and Fitness ASDAN. She lost 2 stone in weight (having had a BMI of over 50), created a fitness DVD, developed and delivered a cooking course and created posters on healthy eating that were displayed around the hospital. The success of her cooking course was not only beneficial to others but also to her, enabling her to learn how to share what she had learnt and grow ever more confident in her abilities.

One patient who at 43 years of age had never achieved any qualification until he completed an ASDAN short course in Sport; the achievement the patient felt was huge. It was the first time in his life he had ever completed a course or obtained a qualification.

Another patient loved to play badminton but always did so without moving her feet. Her study of badminton as part of her Sport ASDAN enabled her to learn how to move when playing – making it much more effective as a form of exercise and adding to her enjoyment of the sport.

Patient feedback reveals just how much they value our approach to education and therapy:

“This course has totally changed my life. It has changed my way of thinking, and how I perceive myself. I don’t want to turn back to crime. This course has made me believe in myself, and that I can do something better with my life when I get into the community”.

“I am excited. In the beginning I could not stand in front of the group and present. Now, I feel comfortable and confident to do it”.

“He (Nash Momori, Peer Trainer Service User Consultant) has been an inspiration. He is always smiling, and he shows me how to build my skills. He helps me to understand how to build my skills by showing me how to do it first, and then talking me through it. I can’t thank him enough”.

 

 


Fishing as therapy?

The Cedar House Fishing Group has been running for over five years and, as it turns out, it’s a bit of a family affair. Paul Wilmshurst took it over from his brother who, along with their mum, all work for Huntercombe. Paul is clearly a passionate fisherman but actually, when you speak to him, it’s his dedication to our patients that really comes through.

Between 4-6 patients go fishing with Paul two to three times a month, sometimes every Sunday (depending on the weather). Sometimes the group go sea fishing, other times they go freshwater fishing at a local Course Fishery.  Paul takes patients with a range of abilities and experience but all develop their skills and make progress  – catching bigger fish as they do so.

Paul was able to teach one particular patient how to tie his own fishing rig and was then able to share the excitement when he caught fish using it. Paul says that you can’t really put into words the satisfaction the patient got from catching fish with a rig he had made himself – nor the intense satisfaction Paul got from helping him to do so.

Patients are detained at Cedar House because of the risks that they might pose to themselves or others – this detention is independently and regularly assessed for its appropriateness by courts of law –  so the risks are properly assessed before Paul takes any of them fishing.  What’s great, however, and what Paul is extremely proud of, is the fact that they have never had a single incident.

He puts this down not just to the tranquil nature of fishing, nor the stillness and focus that a fisherman obtains. He believes that it is also about being in an environment where you see familiar faces, people who recognise and acknowledge you, without the ‘clinical focus’ that is a requirement of the hospital setting.  This helps patients to relax and enjoy a very tranquil everyday pursuit.

And in this environment patients progress and thrive – this is the cornerstone of ‘rehabilitation’, and Cedar House do their best to ensure that all their patients reach their own goals and potential, often introducing them to new skills and experiences on the way. Fishing’s actually not as straightforward as you might think. And catching the fish is only half of the story. Paul also teaches patients how to manage the fish once they have caught it to ensure it can be put back in the water. They need to learn how to reel in the fish, netting and landing, handling and how to enable fish to recover before releasing them. And they do. Mark says that most of his current group are now totally self-sufficient and rarely need help. The satisfaction they gain from being able to do all of this independently is immense.

What better preparation for leaving us?

 

 


Transforming Care in Practice: Eldertree Lodge

The introduction of NHS England’s Transforming Care agenda in 2012 presented significant challenges for commissioned providers of long-stay in-patient facilities for people with learning disabilities and/or autism.

Magnifying these challenges, and the need for radically revised care strategies in the sector, were the significant reductions of in-patient capacity mandated by Building the right support, the NHS commissioning plan published in October 2015[1].

This document outlined a national service model to ensure that Transforming Care delivered on its goal of improving health and care services so that more people with learning disabilities could live to their full potential in the community, with the right support, and close to home.

Re-integrating patients into the community as swiftly and seamlessly as possible, while ensuring they are properly equipped to make what for many will be a difficult transition, means reconfiguring services and embracing new ways of working across a broad range of parameters.

These include care pathways, staff expertise, facility design, managing challenging behaviour, relationships with other providers to facilitate re-integration, and the involvement of families, carers and patients in shaping service delivery.

Demanding though these changes are, they have encouraged care providers to think creatively about how people with learning disabilities who need specialist inpatient care can break what is all too often a dispiriting cycle of admission, extended stays, discharge and re-admission

Among the key mandates of Building The Right Support was that no area of England would need capacity for more than 10-15 inpatients with learning disabilities per million population. Where patients did require more specialised support in-house, their length of stay should be as short as possible. This effectively meant that 25-40% of NHS England-commissioned capacity and 35-50% of inpatient provision would have to close nationally, with alternative care provided in the community.

The impact was even more significant in areas of the country more reliant on inpatient care. That included the West Midlands, where the deadline for implementation of the national service model introduced with Building The Right Support moved forward from March 2019 to March 2018.

This model set out a range of services and support mechanisms around nine core principles[2], such as:

  • Making sure care and support for people with learning disabilities is person-centred, planned, proactive and co-ordinated.
  • Giving them choice and control over how their health and care needs are met, as well as where they live and who they live with.
  • Providing patients with access to specialist health and social-care support in the community
  • Limiting hospital stays and ensuring high-quality services when patients are admitted for assessment and treatment in that setting.

Ashley House to Eldertree Lodge

Within the Huntercombe Group (THG), the standard-bearer for Transforming Care in practice has been Eldertree Lodge, a High Dependency Inpatient Rehabilitation Service for people with Learning Disabilities in Market Drayton.

The service provides rehabilitation and support for adults with learning disabilities who have been in long-stay environments, or who find themselves suddenly unable or unprepared to cope with living in the community.

Eldertree Lodge was previously known as Ashley House Hospital, a low-secure inpatient  service for adults with a primary diagnosis of learning disability.

Aligning facilities and practices at Ashley House Hospital with these principles called for a fundamental overhaul of the existing service model, as well as new relationships with community care providers to make sure re-integration occurred in the right way and at the right pace.

To reflect these changes, Ashley House Hospital rebranded to Eldertree Lodge, offering innovative high-dependency rehabilitation services. Ward sizes were reduced to 6-8 beds maximum, with new purpose-built de-escalation suites on each admission ward. The revised layout, spread over six units, improved staff-to-patient ratios while more closely approximating future community living and recognising that people with learning disabilities cope better in familiar environments with fewer residents and less noise.

Two revised patient pathways were launched: a Male Neurodevelopmental Pathway and a Female Complex Care Pathway, both geared to moving patients back into their home, the community or, at a minimum, a step-down environment as soon as possible. This step-down approach was replicated within Eldertree Lodge, with patients transitioning from a tailored short-stay (3-6 months) admission service to a matching pre-discharge service (6-9 months).

Historically, Ashley House Hospital had performed significantly above the national average on discharge rates: 15 months versus an average stay of 31.6 months nationally. With the reconfiguration of services at Eldertree Lodge, along with newly aligned teams and care pathways, the average length of admission to discharge reduced to 12 months or less.

At the same time, an accelerated pathway created the need for new services that would enable patients to re-integrate into the community as smoothly as possible and avoid unnecessary rehospitalisation.

In alliance with Arch, part of the Staffordshire Housing Group, Eldertree Lodge is developing an end-to-end care model that includes a Supported Living environment, a step between pre-discharge and independent living.

This comprises apartment style accommodation in the community, backed up by outreach support from the Eldertree Lodge team.

A new Positive Behaviour Support Emphasis

A crucial element in delivering person-centred, proactive care at Eldertree Lodge was the adoption across THG of Positive Behaviour Support (PBS) strategies. PBS aims to enhance quality of life by encouraging positive alternatives to challenging behaviour, rather than simply repressing behaviour through restrictive interventions.

To date, we have  nine PBS coaches, two practice leaders and a number of practitioners at Eldertree Lodge, while around 80% of the staff have received Introduction to Positive Behaviour Support training.

The impact has been significant, both on the volume of challenging incidents and the need for physical interventions. A recent cohort study of PBS outcomes at Eldertree Lodge found there had been a 37% reduction in restraints since the PBS programme was implemented.

A Refreshed Community Focus

We have also introduced a stronger community focus  into our services, so that we can equip patients with as many skills as possible to help them integrate and live independently following discharge.

These include educational opportunities, such as horticulture courses or placements in an animal-care college; the onsite Ash Tree Café, run by patients with support from the occupational-therapy team to facilitate vocational rehabilitation and social inclusion; and music therapy in partnership with Nordoff Robbins.

Another facet of boosting patients’ engagement and autonomy to prepare them for independent living is involving them in all levels of service delivery at Eldertree Lodge, such as attending governance meetings or auditing health and safety issues.

A family and carer forum helps these key stakeholders influence services in ways that will support them in accommodating the patient’s return to the community. Approved patient access to digital communications through mobiles or tablets is one other means of easing the transition.

Developing a Best-practice Model

Faced with the tough demands of the Transforming Care agenda, Eldertree Lodge has reconstructed and rejuvenated its service model to offer patient-centred rehabilitation with re-integration into the community at its core.

It has done so without any reduction in staffing, and with only a minor reduction in patient capacity to accommodate the facility redesign.

As a model for best practice within THG, we are now working with other hospital managers to help them implement the learnings from Eldertree Lodge and establish Transforming Care as the foundation of inpatient provision for people with learning disabilities across the Huntercombe network.

By Alan Malin, Hospital Director, Eldertree Lodge

 

[1] Building the right support. A national plan to develop community services and close inpatient facilities for people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition. NHS England. October 2015. Retrieved from https://www.england.nhs.uk/wp-content/uploads/2015/10/ld-nat-imp-plan-oct15.pdf.

[2] Supporting people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition. Service model for commissioners of health and social care services. NHS England. October 2015. Retrieved from https://www.england.nhs.uk/wp-content/uploads/2015/10/service-model-291015.pdf.


Next stage of development for Brain in Hand at Cedar House


The success of our Brain in Hand trial at Cedar House prompted us to consider how else we can use this piece of technology.

Brain in Hand (www.braininhand.co.uk) is currently being used to help patients better self-manage in order to reduce anxiety and crisis incidents, especially when in the local community.

Brain in Hand gives patients easy access to their own personalised diary, reminders, and coping strategies through an app on their phone.  An inbuilt anxiety monitor also allows users to report their emotional state on a regular basis using a simple traffic light system.  This enables support staff to be able to see how patients are feeling, wherever they are, and intervene if needed.

If coping strategies aren’t working and a patient needs help, they can press the red traffic light button at any time and a text message is sent to the allocated phone holder. The allocated phone holder then contacts a trained traffic light responder, who will get in touch with the patient to help to de-escalate the problem. The system also provides a wealth of usage data, including anxiety tracking and problems faced, to help with reflection and planning.

And now we’re developing the app so that staff can use it for patients who are unable to use it themselves. The app is set up so that every single item in a patient’s diary is logged, with each individual step of every item logged. This facilitates absolute continuity of care with incidents minimised or potential ‘crisis points’ managed in the best way possible.

Whilst the idea of an itemised diary may seem fairly straightforward, for some of our patients, particularly those with autism, it is far from that. Some of our patients require an extremely structured approach, with the exact same steps and words to their routine every day. Every question must receive the ‘correct’ answer, phrased using the ‘correct’ words or confusion, frustration and high levels of anxiety for both staff members and patients can ensue.

The Brain in Hand app ensures that all team members understand every step of the patient’s day in finite detail and will know what trigger points may exist and how best to manage them.

But the app does more than that. It enables team members to track responses to suggested solutions using a traffic light system.  Tracking of responses is then reviewed and suggestions for solutions refined based on what has been proven to work best.  Again, this detailed history of what works and when ensures much greater consistency of care, which is critical for some of our more challenging patients.

The end result is settled patients, fewer incidents and hugely reduced pressure on team members. Detailed Diaries (which can take days or even weeks to enter fully) are currently being created for a small number of patients. The team hope to be able to start using the app fully from the end of September. This realistic time scale will enable the team enough time to think of as many potential problems/behaviours and solutions as possible, so that once the app is launched, it is as reliable as possible.