the national high secure services for women rampton hospital
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The National High Secure Services for Women Rampton Hospital. Dr Sue Elcock Consultant Forensic Psychiatrist. Positive about integrated healthcare. Rampton Hospital. Clinical Directorates Directorate 1 -Mental Health Services -National Learning Disability -National Deaf Service - PowerPoint PPT PresentationTRANSCRIPT
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The National High Secure Services for WomenRampton Hospital
Dr Sue Elcock
Consultant Forensic Psychiatrist
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Positive about integrated healthcare
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Rampton Hospital
Clinical Directorates
Directorate 1
-Mental Health Services
-National Learning Disability
-National Deaf Service
Directorate 2
-Personality Disorder Services
-National High Secure Healthcare Service for Women
-Dangerous & Severe Personality Disorder Directorate (The Peaks)
Support Services Security Department Therapies and Education
Department Social Care Services Facilities Department Corporate Services
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Therapies & Education Department
4 Departments – 135 staff / 18 patient areas Occupational Therapy Team Education (including Patients Library) Art Therapies Speech and Language Therapy Operations Support:
• Chaplaincy• Technical Instructors • Relief Pool • Administration
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One National Service Women’s Mental Health : Into the Mainstream Implementation Guidance
2003: one national service
1991 345 women in high security
-Female beds at Ashworth closed in 2003
-Female beds at Broadmoor closed mid 2007
-Female bed at Carstairs Hospital 2008
NHSHSW new build (50 beds) opened January 2007
3 Women’s Enhanced Medium Secure Services (46beds) 2007
1993 - 2000 the average women’s population in prison increased by 111.5% compared to a 42% increase for men
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NHSHSW
50 beds Emerald A 6 Beds -Learning Disability Unit Emerald B 6 Beds -Intensive Care Unit
Topaz 12 Beds -PD Admission/Treatment Ward
Ruby 14 Beds -PD Treatment Ward
Jade 12 Beds -Mental Health Ward
Diamond Resource Centre -Day care services for women
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De-escalation
Quiet Rooms
Low Stimulus
Seclusion
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Referral and Assessment Process
1. Existence of Mental Disorder requiring detention and treatment in hospital.
2. Availability of Appropriate Treatment.
3. Presenting a Grave and Immediate Risk to others.
Referral
Assessment bySenior
Clinicians from NHSHSW
Reports submitted
to Admission Panel
Panel Decision
*Secretary of State Direction to Admit can bypass the above process
and direct an admission
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2008 2009 2010 2011 2012 2013TOTALS
2008-2013
NHS Standard Medium Secure
6 5 6 8 5 11 41
NHS WEMSS 1 5 4 3 2 0 15
Independent Medium Secure 2 8 3 4 2 5 24
HMP 3 5 4 3 4 4 23
Other 1 0 0 2 1 0 4
Totals 13 23 17 20 14 20 107
Referrals
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Admissions
2008 2009 2010 2011 2012 2013TOTALS
2008-2013
NHS Standard Medium Secure
1 1 1 0 1 5 9
NHS WEMSS 0 1 3 1 0 0 5
Independent Medium Secure
2 2 2 3 1 2 12
HMP 1 3 1 3 4 2 14
Return from Trial Leave 2 1 0 1 0 0 4
Other 0 0 0 1 1 0 2
Totals 5 8 7 9 7 9 45
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Conversion Rates
○ 2008 5 admitted from 13 referrals 38.5%○ 2009 8 admitted from 23 referrals 35%○ 2010 7 admitted from 17 referrals 41%○ 2011 9 admitted from 20 referrals 45% ○ 2012 7 admitted from 14 referrals 50%○ 2013 9 admitted from 20 referrals 45%
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Discharges
2008 2009 2010 2011 2012 2013TOTALS
2008-2013
NHS Standard Medium Secure
8 0 0 7 3 7 25
NHS WEMSS 8 1 1 2 0 0 12
Independent Medium Secure
5 5 0 3 0 1 14
Prison 0 1 1 1 0 2 5
Totals 21 7 2 13 3 10 56
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The Population
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MHA (2012)
MHA Section Number of Patients
37/41 22
47/49 7
41(5) 7
3 5
37 3
Total 44
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Length of Stay (2012)
years Number of Patients
0 - 1 7
1 - 2 4
2 -5 22
5 - 10 7
10 - 15 3
15 - 20 1
Total 44
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Challenges
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Co-existing self injury and violence
Balancing the risks to patient and staff
Managing superficial and life threatening self injury
Use of seclusion and mechanical restraint in exceptional circumstances
Recognising and supporting impact on staff
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2009 : 25% of all forensic services incidents (2376 of 9323)per month 173 – 246 staff sickness 5-12%
Oct-Dec 2009: 574 incidents: 30% self injury (173) 48% violence (277)
of 277 violent incidents: 95% to staff5% injury during restraint
9% physical assaults 49% threats/verbal abuse
Jan – June 2009: 230 seclusion episodes (32-45 per month)27 episodes of continuous obs (1-11per month)
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Seclusion and segregation: balance violence and self injury risks
Safe and Exceptional Use of Mechanical Restraint Policy
Trauma and Self Injury Programme: adapted risk reduction approach to self injury
Specialist supervision
Post Incident Defusing and Debriefing (NICE)
Promote staff well being: OH, physio, sickness policy
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Integrated Care Pathway
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Women’s Service Pathway: Assessment stage (incorporating early treatment and engagement)
Concurrent PathwaysLink to ICP Map 4
Assessment Stage:Interventions & Activity
MDT Assessments (6 months)
LEARNING DISABILITY
STREAM
MENTAL HEALTH STREAM
PERSONALITYDISORDER
STREAM
INTENSIVE CARE STREAM
CORE ASSESSMENT SET(2)
CARE STREAM SPECIALIST ASSESSMENTS
(3)
INITIAL MDT FORMULATION(4)
6 MONTH CPA MEETING(5)
CPA CARE PLANLink to CPA Pathway
REFERRAL OUT OF SERVICE
(6)
PATHWAYENDS
COMPLETION OF DISTRESS SIGNATURE
(7)
TASI PROGRAMME
LINK TO ICP MAP 5:GENERIC ACTIVITY
MDT MEETINGS
NAMED NURSE INTERVENTIONS
THERAPEUTIC MILIEU
SOCIAL CARE PATHWAY
HEALTHY LIFESTYLESPATHWAY
TEDPATHWAY
PHYSICAL HEALTHPATHWAY
SECURITY PATHWAY
MDT MEETING:MDT ASSESSMENT PLAN
(1)
MEANINGFUL DAY PLAN(8)
OUTCOMES FOR ASSESSMENT STAGE
(9)
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Women’s Service Pathway: Foundation Stage - Early Treatment and Engagement (6 -12 months)
Concurrent PathwaysLink to ICP Map 4
Concurrent ActivityFoundation InterventionsCore Foundation Interventions
LEARNING DISABILITYCARE STREAM:
FOUNDATION INTERVENTIONS (3)
MENTAL HEALTH CARE STREAM:
FOUNDATION INTERVENTIONS (4)
PERSONALITY DISORDERCARE STREAM:
FOUNDATION INTERVENTIONS (5)
INTENSIVE CARE STREAM:
FOUNDATION INTERVENTIONS (6)
SERVICE CORE INTERVENTION:
TASI PROGRAMME(1)
COMMUNICATION SKILLS GROUP
(8)
MEANINGFUL DAY PLAN(10)
SERVICE CORE INTERVENTION:
DIALECTICAL BEHAVIOURAL THERAPY
(2)
DIRECTLY WORKING WITH ANGER AND AGGRESSION
(7)
SOCIAL CARE PATHWAY
HEALTHY LIFESTYLESPATHWAY
PHYSICAL HEALTH PATHWAY
TEDPATHWAY
SECURITYPATHWAY
LINK TO ICP MAP 5GENERIC ACTIVITY
MDT CLINICAL MEETINGS
NAMED NURSE INTERVENTIONS
THERAPEUTIC MILIEU
ACCESS TO LEGAL SUPPORT AND ADVOCACY
CPA PATHWAYRECOVERY PLANNING
(9)
OUTCOMES FOR FOUNDATION STAGE(11)
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Women’s Service Pathway: Treatment Stages
Concurrent Pathways and Activity
Individual Risk and Offence Focused Work
Core Interventions
PHYSICAL HEALTH & WELLBEING
Link to Primary Healthcare / Healthy Lifestyles Pathway
LEARNING DISABILITY
CARE STREAM(1)
OCCUPATIONAL & ARTS THERAPIES
Link to TED Pathway
INDIVIDUAL VIOLENCE / ANGER MANAGEMENT
(6)
ARSON TREATMENT GROUP(ALSO INDIVIDUAL)
(7)
SUBSTANCE MISUSE TREATMENT PROGRAMME
(8)
CASE MANAGEMENT
CONCURRENT PATHWAYS
LINK TO ICP MAP 4
BEHAVIOURAL ANALYSIS(LD STREAM)
(9)
SUBSTANCE MISUSE AWARENESS GROUP
(5)
MENTAL HEALTHCARE STREAM
(2)
PERSONALITY DISORDER
CARE STREAM(3)
OUTCOMES FOR TREATMENT STAGES(10)
LINK TO ICP MAP 5GENERIC ACTIVITY
MDT CLINICAL MEETINGS
NAMED NURSE INTERVENTIONS
THERAPEUTIC MILIEU
ACCESS TO LEGAL SUPPORT AND ADVOCACY
TASI PROGRAMME:(4)
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Women’s Service Pathway: Consolidation Stage
Consolidation Stage
YES
LEARNING DISABILITY
CARE STREAM
MENTAL HEALTHCARE STREAM
PERSONALITY DISORDER
CARE STREAM
SELF MANAGEDRECOVERY & RELAPSE
PREVENTION PLANS(1)
DISTRESS SIGNATURE(2)
PROMOTING INDEPENDENCE(3)
MEANINGFUL DAY PLAN (4)
MDT REVIEWS / CPA REVIEWSNO
DISCHARGE PATHWAY PLAN(5)
RECOVERY & RELAPSE PREVENTION PLANS
(6)
PROVIDER IN-REACH(SOCIAL CARE PATHWAY)
DECISION TO TRANSFER OR DISCHARGE YES
REFORMULATION ANDRETURN TO PATHWAY
RETURN TO PRISON
MINISTRY OF JUSTICE
NOT SUITABLE
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Women’s experiences of
self injury and trauma
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Audit 2007 Approx 80% of patients had experienced abuse
Most had experienced complex trauma with residual symptoms Often linked to their index offence
76% of women employ self injurious behaviour as a coping strategy Many engaging in life threatening self injury
On average over 50 incidents per month across the ward areas Staff injuries due to intervening to prevent self injury
The Background
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NICE Guidance Self-Harm: longer-term management (133) Nov 2011
The key priorities for implementation when working with people who self-harm include:
Trusting supportive relationships Awareness of stigma and discrimination Non judgemental approach Involvement in decision making about treatment and care Foster autonomy and independence where ever possible Continuity of therapeutic relationships Information communicated sensitively
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The National High Secure Healthcare Service for Women Trauma and Self Injury Programme
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Positive Risk Reduction Through Systemic Change
3 levels:
Proactive Approaches educating patients and staff about living and working with self injury and the impact of trauma
Interactive Approachesto create positive ward atmospheres which focus on managing and minimising self injury in a way which is helpful to all who live and work there
Enhance Resources in CAT, DBT, CBT and trauma therapies (e.g. EMDR) to support women to use different ways of coping
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Level 1: Proactive Approaches
Skincare and Camouflage
Training
Self help packs
Trauma education groups
Wound care pack and training
Staff TrainingPatient involvement
Patient Rep group
Wellbeing groups
Enhancing capacityProactive approaches
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Level 2: Interactive Approaches
Sensory signatures
Individualised Distress signatures
Guide to aid helpful responses
Shared formulation
Adapted approach to Reducing harm
Champions Staff/patients
Ward milieu
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Level 3: Therapy Interventions
Cognitive Analytictherapy
CAT
Cognitive Behavioural Therapy
CBT
Eye Movement Desensitisation and
Reprocessing EMDR
Dialectical Behaviour Therapy
DBT
Therapy OptionsIndividual/Group
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‘I now understand the difference between when I am impulsive and when I am spontaneous’
‘It has helped me trust my named nurse and the
team, they get where I am coming from, I can now
ask them when things get bad in my head’
‘I don’t feel so ashamed to talk about how it feels inside when
everything builds up. Stops me hitting someone or
cutting my arms’
‘It gives me something that’s just about me , not what I’ve done’
‘It gives me a framework as a nurse to gain understanding of what the woman is
experiencing from her own view”
‘opportunity to look at what helps reduce distress
It is what I should be doing as a nurse, this aids recovery’
‘The most helpful thing was learning about the
vicious cycles I didn’t realise that avoidance
doesn’t help.’
‘I would like to share what I have learnt with my mum I think she will
understand me better.’
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No of incidents of Self Harm in Women's Service1 Apr 2009 to 31 Dec 2013
0
10
20
30
40
50
60
70
80
90
No. o
f Inc
iden
ts
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Dialectical Behavioural Therapy
Focus on regulating emotions, mindfulness, distress tolerance and acceptance
Recommended by NICE for BPD where recurrent self harm is a priority
Foundation treatment to women with personality disorders
Expanded provision to two DBT groups running continuously including an adapted group
Preparatory work before full engagement
More responsive to needs of women
Weekly therapy group and individual session
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Cognitive Analytic Therapy
Focus: patterns of relating to self and others and the therapeutic relationship
Integrative approaches recommended in NICE BPD guidelines
Expanded provision by: supervision of CAT Trainees (Practitioner and Psychotherapist) specialist placements for final year Clinical Psychology and Forensic
Psychology Trainees
supervised clinical practice for qualified staff
Weekly sessions via 16 or 24 sessions
Therapy tools
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Cognitive Behavioural Therapy
•Focus on thinking, behaving, and feeling
•Recommended in NICE Guidelines on PTSD
•Provided by TASI Programme Co-Leads
•Programme support for CBT training
•Weekly therapy sessions
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Combines elements of exposure therapy, cognitive therapy, and body work
Also recommended in NICE Guidance on Post-Traumatic Stress Disorder (PTSD)
Pilot project started April 2010
Challenges implementing
Eye Movement Desensitisation and Reprocessing
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The Future
•Develop physical healthcare provision - physical healthcare suite
•Truly national service working with Scotland and N Ireland
•CIPs
•National Women's Personality Disorder Strategy
•National debate about number of high secure beds needed
•WEMMS evaluation
•Need to establish seamless pathways for women through the different tiers of secure services with seamless entry/exit criteria