The Enhanced Trauma Pathway (ETP) at Berkshire Healthcare NHS Foundation Trust was established in 2018 to manage high demand on a highly specialist psychology team called the Berkshire Traumatic Stress Service (BTSS). The ETP is used to treat complicated cases of Post-Traumatic Stress Disorder (PTSD) within the IAPT service. However, because of the ETP there is now a cohort of Service Users (SUs) presenting to IAPT with a higher complexity than has been typical, presenting new challenges for the service. We aim to evaluate and redesign the ETP within IAPT to meet the needs of the changing population.

Clinically Led workforcE and Activity Redesign (CLEAR) is a workforce transformation methodology with four unique stages: i) Clinical Engagement: in-depth qualitative analysis of interview data from staff ii) Data Interrogation: cohort analysis using clinical and workforce data visualisations and analysis, iii) Innovation: developing novel solutions with insights from triangulated qualitative and quantitative data, iv) Recommendations: formulation of new models of care (NMOC) and smaller quick high impact service innovations. Thematic analysis was used for the qualitative data. Quantitative data analysis was conducted using the IAPT dataset.

27 semi-structured interviews were conducted with staff. SUs on the ETP had longer waiting times, their treatment took longer (18 sessions for ETP Vs 12 for core step 3) and they had lower recovery rates: 32.9% for ETP, 49.9% for core step 3 in IAPT and 57.3% for the whole IAPT service. SUs on the ETP presented with increased risk concerns, often not mitigated by stabilisation work offered. Thematic analysis also identified challenges with recruitment, a lack of qualified staff and inefficient use of skills across the pathway. Staff well-being was found to be paramount, however supporting staff was found to be challenging due to national constraints placed upon IAPT and the targets the service is asked to achieve. A series of recommendations were made including three options for a NMOC. The options suggested different ways to redesign the pathway including an option where there would be a trauma only team within IAPT working exclusively on the ETP.

This evaluation highlights the challenges for the ETP and identifies NMOC to reduce their impact on the service. Further work is required to assess the NMOC once it has been implemented and to further evaluate the needs of the SUs presenting to this service.

Forensic service-users (SU) are often transferred between units at short notice, with little information about their new ward and unaddressed concerns. The findings of our first Plan, Do, Study, Act (PDSA) quality improvement project exploring SU's transfer experiences from medium to low secure units during COVID-19 in East London. Whilst unsettling, it may also impact therapeutic progress due to difficulties in developing new relationships with clinicians and ward residents. Our second PDSA cycle explores SU concerns and identifies improvement recommendations.

Five SUs consented to take part in the experience-based co-design approach. Remote semi-structured interviews explored experiences and suggestions for improvement. Audio transcriptions were thematically analysed to assess information provision, transfer expectations, new ward perceptions, available support and overall reflections.

Recipients of a tour prior to moving felt most informed about the transfer and reported not requiring further information. Without the tour, some SUs were unaware of the name or type of their future ward. Therefore, SUs recommended everyone should have a tour prior to transfer, or where not possible a video tour. Two weeks was felt to be the ideal amount of notice prior to transfer and in the absence of this, weekly updates during ward round. Being able to talk to an SU who had recently moved to the new unit would be ideal, or in lieu of this a pre-recorded question and answer (Q&A) video.

SUs were interested in the new ward policy regarding leave and mobile phone criteria. A recurring issue involved SUs being promised unescorted leave on the new ward, but this not taking place. Importance was also placed on the family being updated during the transfer and moving with a preferred staff member. Many SUs felt the process was smooth yet held concerns about forming new friendships. They felt their psychologist, primary nurse or ward manager were easiest to approach with concerns. On the transfer day, SUs benefitted from the encouragement and congratulations from the old team, however cited feeling rushed when moving.

Implementing a pre-recorded tour with unit facility highlights and a recent SU transfer Q&A video would improve the transfer experience. Having clear policies regarding leave and mobile phone criteria prior to moving improves clarity. Our approach to include SUs in the transfer meeting with both the new and old wards ensures transparent expectations. We continue to monitor the success of these interventions on transfer experience through further PDSA cycles.

The Tony Hillis Unit (THU) is a locked rehabilitation unit for men aged 18–65 years with Treatment Resistant Psychosis, with or without mild personality disorders; drug and alcohol misuse; and challenging behaviour. The multi-disciplinary team including psychiatrists, psychologists, nurses, occupational therapists and specialist pharmacists offer service-users a holistic, personalised and pragmatic management plan to facilitate an improvement in their level of functioning. This service evaluation aimed to review the effectiveness of our intervention as a unit as defined by functional outcome at six months pre- and post- admission.

A retrospective, mirror-image study design was used to collect data. Data were obtained from South London & Maudsley's Electronic Patient Journey System (ePJS) records. All patients discharged from THU over a two-year period, from May 2019 to May 2021, were considered in the study (n = 25 patients). Two service users died during the evaluation period and were excluded. A further service user was excluded as he had an admission length less than 28 days. Variables recorded included patient demographics and the presence of biopsychosocial interventions at THU including Clozapine initiation, engagement in weekly 1:1 occupational therapy (OT) and 1:1 psychology sessions. The functional status at six months pre-admission and post-discharge was defined by placement type, graded in terms of level of support; 1 = Psychiatric Intensive Care Unit, 2 = Acute ward, 3 = Rehabilitation service/Prison, 4 = Care home, 5 = Supported accommodation and 6 = Independent living. The change in patient acuity pre- and post- THU was compared using Wilcoxon-signed rank test.

23 service users were included in this evaluation. The average admission length was 365 days, and average age at admission was 38 years. The difference in patient acuity before and after THU intervention was statistically significant (P < 0.005), with an overall reduction in level of placement support required. The most common placement prior to admission was an acute ward, compared to a rehabilitation service six months after discharge. 60% of patients (n = 13) were newly initiated or re-titrated on Clozapine during their admission, with a further 4 patients already on Clozapine. 82% of patients engaged with 1:1 weekly OT and 72% engaged with 1:1 weekly psychology sessions.

This study demonstrates the effectiveness of our role as a locked rehabilitation unit. It outlines some of the key biopsychosocial interventions likely contributing to this, including initiation of Clozapine.

There is a well-known bidirectional relationship between mental and physical health. A thorough mental and physical health assessment of new inpatients on admission is crucial to assess possible organic causes of psychiatric presentations and enable appropriate treatment to be commenced in a timely manner. We noted a pattern of incomplete clerking, leading to delays in commencing treatment and increased workload pressure on the ward medical team. Our audit aims to assess how thoroughly and in what time frame patients' admission assessments are being completed on an acute psychiatric inpatient unit.

A sample of 20 patients was used for each cycle. Eight components were identified from the Trust clerking procedure. These were a full psychiatric history, capacity assessment, prescription chart, physical health systems review, physical examination, blood tests, ECG and VTE assessment. The expected standard was completion of all of the above at the point of admission or, if applicable, adequate documentation of patient refusal with documented reattempt within 24 hours.

Electronic patient records were retrospectively reviewed to identify whether each component was completed, the number of days from admission to completion and if completed by the clerking doctor. Evidence of documented patient refusals and the number of incomplete draft entries were noted.

Initial results showed only 20% of patients (n = 4) had the full expected clerking procedure completed at admission. Physical health assessments (ECG, blood test, physical examination) had the lowest completion rates. When components were not completed by the clerking doctor, there was often a delay of several days from admission to completion of by the ward day team. For 50% of patients, some assessments were never completed (without adequate refusal documented). Eight patients did not have a completed VTE assessment by the point of discharge.

Reasons were identified for the poor completion rates of clerking assessments. These included a lack of understanding by on-call doctors about the importance of completing all assessments, unfamiliarity with ward equipment, lack of adequate handover to the ward medical team and staffing pressures. A new handover checklist was introduced for clerking doctors to use and enable better communication with the ward team. Clerking procedure summaries were displayed in on-call rooms and additional teaching was organised.

People with mental health issues have challenges in accessing medical care and it is hypothesised that this may result in a significant number failing to receive protection from COVID -19 by means of vaccination. This study aimed to identify the number of inpatients on a psychiatric general ward (Meridian ward) between May 2021 and June 2021 who were fully vaccinated against COVID-19 so that unvaccinated patients could be offered vaccination during their inpatient stay.

Data were gathered on the COVID-19 vaccination status of all patients on Meridian ward (inpatient mental health ward) admitted between May and June 2021. This was a total of 10 patients. This information was gathered directly from the patients, their summary care records and GP records. We also audited whether the patient's vaccination status was recorded in the notes.

50% of the patients were fully vaccinated. 20% had received one vaccine and 30% of patients were unvaccinated. 20% of the unvaccinated patients received their first dose during admission.

Patients with mental health issues sufficient to result in psychiatric admission face additional challenges when it comes to receiving a COVID-19 vaccine. It is important that healthcare workers are aware of this and facilitate interventions that maximise vaccination in this at-risk group. To improve uptake among this group it is recommended:

• • Patients’ vaccination status is assessed and recorded during inpatient admissions.

• • GP surgeries should identify patients on their database with mental health issues who are unvaccinated and providing these individuals with support around accessing information, transport or providing vaccinations at patient's homes.

• • There should be clear documentation of vaccination status on summary care record and ward notes.

VTE-related deaths are a leading cause of preventable mortality amongst all hospital inpatients. Psychiatric inpatients are at greater risk of this, due to administration of antipsychotic medication and longer inpatient stay. This is particularly significant during the COVID-19 pandemic, not least as it is a disease known to cause hypercoagulability, but also due to an increase in mental illness and extended admission, resulting from an overwhelmingly run social service. The objective is to analyse VTE risk assessments performed for the 23 patients at Lambourn Grove, a continuing care unit for old age psychiatric inpatients, diagnosed with dementia. The aims are to assess; the frequency at which VTE risk assessments are performed, the accuracy of each assessment and the subsequent management and appropriateness of preventative measures taken.

A retrospective study was conducted of 23 service users. Data were collected from the VTE assessment form on the local electronic patient record system, and analysed to assess compliance with local guidance. GP records were consulted to cross check data and ensure accuracy of information inputted. Improvement measures include presenting at the local teaching session and implementing a mandatory monthly review onto the ward round proforma. A second cycle will be carried out to assess the success of these interventions in improving best medical practice.

Of the 23 service users, 20 patients had their VTE risk assessment completed on admission and there was a delay of over a month with the remaining 3 patients. Of significance is that of all initial VTEs, 6 out of 23 contained inaccurate details, such as omission of comorbidities or a subjective assessment of mobility, indicating the need to use a standardized tool which allows for comparison across time. The mean admission duration for all 23 inpatients, as of February 2022 was calculated to be 16.2 months, with a range of 2 and 59 months. 15 patients did not have their VTE risk assessment repeated during admission, and of these 2 did have a change in their risk profile, indicating non-adherence with NICE guidelines.

This study has identified significant areas for improvement, specifically the need for clear timing for repeated VTE assessments, consistent sources of patient's medical history and documentation of mobility status. The project has highlighted the need for a more robust VTE assessment protocol which is currently being developed, to improve patient mortality and outcomes.

We aim to explain more about PMDD in young people and explore the evidence looking at the role of CBT as an intervention. We aim to develop high-quality psychoeducation material with the involvement of young people, to be able to offer clinically relevant information and empower young people with PMDD.

A literature search was conducted in 2019 and updated in February 2022 using the Cochrane Library, Psych-info, MEDLINE, Cinahl, EMBASE and Google Scholar, to look at the evidence available for CBT in young people with PMDD or PMS. The search included PMS as well as PMDD due to the heterogeneity in definitions used in studies.

Focus groups with young people are underway to develop high quality written psychoeducation material about PMDD.

There were no specific studies looking at CBT as an intervention in young women under the age of 18 with PMS or PMDD. There was one intervention study with a treatment arm of psychoeducation in 62 young people under 18 with PMS versus a no treatment group (Taghizadeh 2013), with improvement in symptoms after 3 months from baseline reported.

There were more studies available in women over the age of 18. The search identified 3 meta- analyses in 2009 and 2012 (Busse 2009, Lusty, 2009; Kleinstauber 2012) and a more recent systematic review (Landolt 2020). Kleinsteiber et al included 22 RCTs, with a median age of 39, and broadly showed CBT to have a small to medium positive effect size, although any conclusions were limited due to the small numbers involved in the individual trials and methodological flaws. Landolt 2020 looked at CBT or elements of CBT as an intervention arm over the last 30 years or so in woman of all ages. Variations of CBT including virtual, group, couple and psychoeducation alone were included, and all were reported to have favourable outcomes.

There is a huge gap in research looking at PMDD in the adolescent population. Translating research from adults is not ideal. Increasing awareness and developing psychoeducation is a step in the right direction.

It has been well publicised the pressures on inpatient bed capacity within mental health services in recent years. The RCPsych have stated in their publication ‘Exploring mental health inpatient capacity’ that bed occupancy has risen above their recommended 85% occupancy target in most areas. Waiting lists for beds have also grown. The aim of this project was to identify whether there could have been any extra community resources in place that could have prevented admissions to hospital within an older adult CMHT. This in turn reducing the demand on inpatient beds.

Inclusion criteria: All patients from the older adult CMHT admitted to either an organic or functional mental health inpatient bed between the 1st September and 31st December 2021.

All patients who met the inclusion criteria were discussed as part of a panel consisting of members of the MDT who were involved in the patients' ongoing care. The panel discussed each patient and individually scored each admission on a scale of 1–5 (where 1 was deemed to be very avoidable and 5 completely unavoidable). Where an admission did not score a 5 we considered whether anything could have been in place to have prevented the admission.

Our search identified 21 patients who had been admitted to the respective old age psychiatry ward during our period of interest. The predominant diagnosis of these patients was vascular dementia (n = 5), followed by Alzheimer's disease (n = 3). Following our consensus panel discussion, we identified that the most common reason for admission to hospital was for management of behavioural and psychological symptoms of dementia (n = 10), followed by increasing patient vulnerability (n = 4) in the community. Carer stress was a theme in 2 admissions. Following panel discussion regarding potential avoidability of admission, we identified that 14 out of the total of 21 admissions scored a 5, 1 scored 4, 1 scored 3, and 5 scored 2.

Behavioural and psychological symptoms of dementia continues to remain a significant clinical challenge and was the most common reason for admission in our patient cohort. The majority of admissions to hospital in our cohort were deemed unavoidable as a result. However, we identified that carer stress was a significant theme in 2 out of our 21 admissions, suggesting potential scope to implement services which may reduce carer stress and ultimately, prevent hospital admission.

High Dose Antipsychotic Therapy (HDAT) prescriptions and combinations of antipsychotic agents are not currently recommended as standard practice by the RCPsych. College guidance (RCPsych, CR 190) advises that there is “little convincing evidence that off-label prescription of doses of antipsychotic medication above the licensed dosage range has any therapeutic advantage in any clinical setting” and that “any prescription of high-dose antipsychotic medication should be seen as an explicit, time-limited individual trial with a distinct treatment target”. Despite this, both national and local data demonstrate that HDAT has continued to be used regularly across psychiatric inpatient settings, often out of hours and often secondary to the use of PRN Antipsychotics, without a clear treatment plan or rationale. My aim was to create a simple, accessible, online tool that would allow prescribers to quickly and efficiently calculate the BNF percentage of any antipsychotic prescription and that this will enable safer prescribing.

With the support of a web-developer, I developed an online tool quickly and easily calculate antipsychotic BNF percentages. The tool can be found here: www.hdat.co.uk

The HDAT Helper has been well received at local presentations and I have recently gained the support of senior management at Southern Health NHS Foundation Trust to develop an education programme on HDAT and the HDAT Helper to expand use of the tool across Southern Health.

The current expert guidance, clinical research and my own audit work demonstrates that there are ongoing issues with the prescription of high dose antipsychotics and that at times this occurs inadvertently when different agents are combined.

I believe that the HDAT Helper can make prescribing of antipsychotic agents clearer and more efficient and as a result significantly improve patient safety.

To determine whether there are any gaps in cardiometabolic monitoring within primary or secondary care for people prescribed antipsychotic medication. A well-established system of cardiometabolic monitoring and checks has been implemented for patients with psychosis and bipolar in secondary care. It was unclear whether patients without these diagnoses were receiving the same level of monitoring.

Data were collected retrospectively from case notes of service users under CMHRS Reigate. We included all patients from three GP practices (100 patients) and identified all who were prescribed antipsychotics and their diagnoses. The GP practices were contacted to determine whether a system was in place to flag physical health monitoring requirements for service users on antipsychotics regardless of diagnosis. The results were used to calculate the potential number of patients across the entire trust who were at risk of not receiving cardiometabolic monitoring.

24/100 patients were prescribed antipsychotics without a diagnosis of psychosis or bipolar. 11/24 had a diagnosis of Emotionally Unstable Personality Disorder. Quetiapine was the commonest antipsychotic. None received routine cardiometabolic monitoring.

The total caseload for all 11 adult community teams in the Trust is 2434. If prescribing and monitoring practices are similar 584 individuals may be affected.

2/3 GP practices responded. Both confirmed that they would only conduct cardiometabolic monitoring when taking over prescribing/on discharge from secondary care if specifically requested to do so.

This service improvement project has identified a significant group of patients who aren't automatically offered cardiometabolic monitoring in secondary care.

Private correspondence from Professor David Taylor confirms that these patients would also benefit from monitoring when prescribed doses that are more likely to cause adverse effects (Quetiapine > 150mg/Olanzapine >5 mg Risperidone >2mg)

Secondary services need to identify these patients and include them in routine cardiometabolic monitoring.

Secondary services need to work closely with primary care to ensure that responsibility for checks is agreed and handed over when necessary.

Background: The Driving & Vehicle Licensing Agency (DVLA) states: “Doctors and other healthcare professionals should: advise individuals on the impact of their medical condition for safe driving ability and also advise the individual on their legal requirement to notify DVLA of any relevant condition”. Within mental health, the guidance states that depression or anxiety associated with “Significant memory or concentration problems, agitation, behavioural disturbance or suicidal thoughts” must be reported to the DVLA. Aims: Identify whether information was collected on driving status of patients presenting with depression/anxiety and self harm. Identify whether accurate advice was provided and documented. Implement changes that would improve compliance with guidance.

We reviewed notes to collect baseline data for 3 weeks prior to commencing interventions, then weekly for 2 months from November 2021. Cases were defined as: those presenting to Liaison Psychiatry (LP) with an act of self-harm either on antidepressants or with a confirmed diagnosis of depression/anxiety on their record. Each week, the notes of 10 cases were reviewed for evidence of documentation of driving status and advice regarding DVLA guidelines.

Week 1: Email communication to team highlighting the guidance, responsibilities and where to document.

Week 2: Driving status discussed in handover daily to increase awareness and identify/address concerns.

Week 3: Repeat email to team.

Week 4: DVLA guidance posters placed in LP office.

Week 12: Teaching session by Occupational therapist from regional driving assessment centre.

Data were analysed for 90 patients over 9 weeks. 52% were female, and average age was 33 years. Relevant documentation was only made on week 1 (10%) and week 4 (20%). No documentation of either driving status or advice given were made in any of the other weeks analysed.

Achieving compliance with guidance was difficult. Email communication was the most effective intervention. A group discussion to identify drivers of poor compliance found that clinicians failed to ask as the questions were not routine practice, and some voiced concerns about the potential implications of advice (worsening therapeutic relationship or increasing social isolation/implications for employment). Future plans include adding a prompt about driving on the electronic risk assessment, and specific training in the staff induction.

Inpatient admissions during the COVID-19 pandemic went up in the regional unit by 18%. This included a 50% increase in Eating Disorder Presentations and more complex SMI requiring admission to Beechcroft. Beechcroft is the regional inpatient unit for CAMHS in Northern Ireland. This project aimed to improve staff joy in work by 30% by June 2021, following what was one of the most difficult years to be a health professional with the COVID-19 pandemic.

We used the IHI Joy in Work methodology along with our own rating scales in the inpatient unit.

Several PDSA cycles were carried out including focus groups, gathering baseline data from different wards, and our change ideas- Beechcroft stars nominations, Virtual Quizzes and Staff recognition certificates.

Baseline data on our run chart demonstrated a bad day median in Beechcroft with 4.3 being the score.

With the PSDA cycle we demonstrated a 33% improvement in good day scores with a median of 1.4.

We have learnt that Joy in work comes from recognising the work already being done and rewarding the efforts our staff go to.

Spread and scale with Beechcroft stars now part of fortnightly MDT meeting and management meeting. Also rolled out to a community mental health team.

Joy in Work comes from the team. Recognising the efforts of the team is central to this. In particular during a pandemic.

We sought to assess the degree, nature and impact of poor audio quality during ward rounds for individuals attending remotely using Microsoft Teams. We aimed to evaluate attendee experiences of audio quality against our expectation that due to the existing ward microphone system using a cardioid polar pickup pattern that attendees would have difficulty hearing all members of the multidisciplinary team, as well as the patient, gathered in the conference room. We also hypothesised that after switching to an omnidirectional sound recording system, we would observe an improvement in attendee satisfaction with audio quality during ward rounds.

Individuals who had remotely attended ward rounds at Lesney Ward, Oxleas NHS Trust between 01/11/21 and 01/01/22, mainly patient family members and community care co-ordinators, completed a digital feedback questionnaire regarding audio quality. There was no exclusion criteria. Data from Likert scale questions were analysed with descriptive statistical tests (mode and distribution of responses). As minimal demographic data were obtained, inferential statistical tests were not used. Qualitative data were analysed using thematic sorting based on prevalence of themes in the data.

Feedback was provided by three family members, one ward team member and six members of the community mental health team prior to the intervention. Pre-intervention feedback indicated high levels of dissatisfaction with 6/10 respondents reporting they were “dissatisfied” and 1/10 “very dissatisfied”. Only 3/10 of attendees reported being able to hear and understand all individuals physically present in the room. In addition, respondents agreed that the audio quality was poor (modal response “bad”, 6/10), and that the sound quality impacted upon their experience of the ward round (modal response “yes, greatly”, 6/10).

The three most common main issues reported by respondents were: people speaking too far from the microphone (7/10), voices sounding muffled (6/10), and too much background noise (4/10). Using their own words, respondents described how the ward round sound quality made them feel. Common themes identified through thematic sorting included: distress, difficulty in understanding information / management plan, ward round prolongation and inability to comprehend the patient or staff.

In conclusion, we found that when using an in-built laptop microphone with unidirectional pick-up remote ward round attendee satisfaction was poor, though this improved with the introduction of an omnidirectional system. Key areas for improvement include assessment of optimal positioning for adequate audio pick-up, and the introduction of automatic transcription for individuals with hearing impairments.

The aim of this QIP was to identify whether the information obtained during routine physical health reviews was being adequately handed over during discharge from the Sheffield Home Treatment Team within discharge summaries. Individuals with serious mental illness have a significantly higher all-cause mortality rate than those without, much of which is due to preventable physical health conditions. Due to this, the Home Treatment Team aims to complete a Physical Health Review (PHR) for every patient under their care as per guidelines. It is important that these examinations are performed, however, it is equally important that the results of PHRs are communicated to the patient's primary care physician upon discharge. Communication between services is vital for continuity of care and to ensure that identified problems are managed effectively. On discharge, relevant data from these investigations should be communicated to the service user's registered GP surgery for appropriate follow-up care. Performing investigations without informing the service user's primary physician is an inefficient use of resources and may result in unnecessary repeated investigations and procedures. There is not currently an official system in place to assure that the investigations and results of PHRs are summarised and communicated upon discharge.

There were two steps taken in this stage of the QIP. First, a questionnaire was distributed to all members of the Sheffield Home Treatment Team, including medics, nurses, and STR workers. The responses were compiled and analysed to form the criteria and standards for an audit of previous discharges. Following this, an audit was performed for the months of June-July 2021, data were kindly collected by junior doctors. This data looked to determine whether previous discharges met the criteria and standards set by the questionnaire.

The results of the audit showed that the discharges did not meet the standards set, with many containing little to no information. Only 49% of the service users with physical health reviews had any information provided on discharge. Of these, the contents of the summaries were varies and inconsistent, resulting in a significant amount of information becoming unavailable to the service user's GPs.

• 1. The current system is insufficient in terms of handing over physical health information collected during investigations performed by the Home Treatment Team.

• 2. A proposed solution will be implemented in the coming months.

• 3. A re-audit will be performed to complete the audit cycle and assess the efficacy of the proposed solution.

To reduce monthly bed days for children and young people (CYP) aged under 18 years admitted to adult psychiatric beds by 50%

QI tools used included driver diagram, stakeholder analyses, process mapping, ishikawa diagram, pareto chart and interviews with CYP and carers to gather qualitative data. Monthly data were collected on all admissions of CYP to adult mental health beds. Change ideas/ process changes included:

• • Early senior psychiatric CAMHS review for all CYP admitted to adult psychiatric beds (same or next working day)

• • Increased access to CAMHS medical records for out of hours staff

• • Admission of all appropriate under 16's to paediatric beds instead of adult mental health beds

• • Short test of change of staffing CAMHS specialist nurses over a weekend

• • Develop alternative non-health crisis support/bed for CYP

• • Develop Personality Disorder (PD) pathway

• • Early senior CAMHS psychiatric review was associated with a reduction in CYP admitted to adult mental health beds from a median of 20 days a month to 2 days a month without an associated increase in CAMHS inpatient admissions

• • Pareto chart showed that Personality Disorder (PD) was the commonest diagnosis

• • Access to CAMHS medical records for all out of hours psychiatric medical staff was increased from 13% to 100%

• • Routine admission to paediatrics for all under 16's was agreed with paediatric medical and nursing managers but not sustainably implemented

• • There were no acute referrals to the CAMHS specialist nurses over the single weekend short test of change

• • Development of an alternative non-health crisis support/bed and development of a Personality Disorder (PD) pathway is still in process

The primary outcome measure was successfully met with the median bed days of CYP admitted to adult mental health beds sustainably reduced from a median of 20 days to 2 days. This was associated with the implementation of routine early senior psychiatric CAMHS review and increased access to CAMHS health records for all medical staff providing psychiatric out of hours assessments. The change ideas including development of different admission pathways (paediatrics and non-health crisis bed), weekend CAMHS specialist nurses service and development of a personality disorder pathway were not implemented sustainably. The pathways of care around CYP presenting in crisis are complex. Making sustainable improvements in complex adaptive systems is complex and challenging but not impossible.

To establish a baseline of staff experience and confidence in autism/LD. To inform how we deliver training going forward. To collect good practice examples of reasonable adjustments. To ascertain knowledge about the appropriate recording for information related to Autism/LD

All clinical and non-clinical staff of Leeds &York Partnership Foundation Trust(LYPFT), Bradford District Care Foundation Trust(BDCFT), South West Yorkshire Foundation Trust(SWYFT), Voluntary sectors, Local authority and Leeds Community Health Care NHS Trust (LCH)were invited to take part in the anonymised “Staff Autism and LD Survey” through the various trust wide email bulletins. Smart Survey was the platform used. It took about 5–7 minutes to complete, and the survey period was from 21/09/21 to 01/11/21

A total of 225 members of staff across six organisations took part in the survey.

76% (170) were from LYPFT, 16(7%) from Voluntary Sector Organisations, 6%(14) from Local Authority and 3% from LCH 3%(7), Missing 14(6%), BDCFT 1%(2), SWYPFT 1%(2)

The majority were nurses 23% (52), followed by psychologists 10% (22).

18% (41) stated they would be interested in becoming an autism champion for their team/service.

Although 89% (200) had heard of the term “reasonable adjustments”, 36% (81) had never seen a ‘hospital passport’ for an autistic or learning-disabled service user.

Only 24 (11%) said they knew where to record reasonable adjustments on the electronic patient record

In general staff were marginally more confident in making reasonable adjustments for people with autism than those with LD

Majority of staff preferred : face-to-face training, followed by e-learning and then videocall.

Generally, respondents reported feeling neutral or confident with respect to their confidence in recognising, diagnosing, and working with patients with autism. The number of staff that have indicated interest at becoming Autism champions is a testament to the growing interest and increasing awareness about Autism.

Regarding learning disability, respondents generally reported feeling neutral or confident across the three areas of recognising moderate to severe learning disability, recognising mild learning disability, and managing/treating mental health problems in service users with learning disability.

The very high number of staff (89%) that have heard of the term “reasonable adjustments” is quite commendable and is useful to know when planning what level to ‘pitch’ training in this area.

It is interesting however that staff feel more confident at making reasonable adjustments for people with Autism, rather than for LD. One wonders whether it is due to the increasing media publicity about Autism.

The paediatric wards support many children presenting with psychosocial crises. This has been increasing in recent years. NICE quality standards recommend that children who have self-harmed receive: a comprehensive psychosocial assessment, are assessed within 24 hours of referral if at high risk of suicide, a collaboratively developed risk management plan and monitoring to reduce risk of further self-harm. We aim to measure the number of referrals made by hospitals for acute psychiatric presentations and the adherence to the above quality standards by the Service for Adolescent and Families in Enfield.

We retrospectively audited inpatients referred by North Middlesex hospital and Barnet hospital. Referral data were collected over 5 years. Data collected between April 2018 and March 2019 were evaluated to review good practice and adherence to the NICE quality standards. For each patient, we collected data on whether they have had a comprehensive psychosocial assessment, if the assessment was completed within 24 hours, 7-day follow-up review and a documented risk assessment.

There has been a 141% increase in hospital referrals to the service from 2014/15 to 2018/19. The service had 130 referrals between April 2018 and March 2019. 72% of referrals came from North Middlesex hospital and 28% were from Barnet hospital. Ages were between 5 and 18. Girls formed 74% of all presentations. 87% of patients presented with deliberate self-harm, suicidal ideation or suicide attempt. Of all referrals 100% had a comprehensive psychosocial assessment, 93% were seen within 24 hours of being referred, 97% had a documented risk assessment and 92% had a 7-day follow-up review.

Self-harm and suicidal ideation in children are rising, especially among girls aged 13 to 16 years (increased by 68% between 2011 and 2014). The gender inequality in our referrals further supports these findings. Higher rates of self-harm have been shown in more deprived areas and could be associated with gang involvement, bullying, abuse, gender identity and family issues. We have developed an assessment protocol and safety plan, are liaising with hospitals daily to arrange assessments and follow-up. Paediatric nurses have been trained in the time to talk programme and a full-time crisis liaison nurse has been employed. This will be re-audited to measure effectiveness of interventions.

To ensure an appropriate treatment pathway is available to patients diagnosed with Depression a STEPPED care model where different types of intervention are offered depending on the patient's experienced severity of Depression. However, a great percentage of patients continue to experience disabling symptoms and fall into the Treatment Resistant Depression (TRD) category. There was a need to review the options available within local Mental Health Services (MHS) for the treatment of patients with depression and TRD.

A new clinical pathway was designed to provide access to patients to emerging treatments, such as EsKetamine, Vagal Nerve Stimulation (VNS) and repetitive Transcranial Magnetic Stimulation (rTMS). After calculating the local impact of depression to patients, trust resources and society we extrapolated our calculations to neighbouring Trusts covering the South West. A newly developed business plan demonstrating the need for new treatment options and the benefits, financial and otherwise, was presented and underwent various approvals levels by the Trust Governance and Executive Committees and local commissioning groups, before being able to proceed. Within the original business plan, rTMS and VNS were offered in addition to the existing ECT as parts of a new treatment pathway. We are now in the process of incorporating EsKetamine and Transcranial Direct Current Stimulation (tDCS). The clinic was set up in March 2020, just at the beginning of the pandemic, which halted operations for quite a few months before being able to resume recently

We have managed to treat patients with both VNS and rTMS from our Trust, as well from surrounding areas. Patients have already experienced benefits in the recovery from symptoms. The new service has provided another line of support for colleagues in offering bespoke treatment plans to their patients and patients have appreciated having access to new non-traditional treatment options.

Although there has been a primary result in improving patient care, income generation is also possible by positioning the Trust in the forefront of new therapeutics and allowing the provision of service to expand to neighbouring Trusts and private patients. Other benefits are associated with the Trust's reputations and kudos being enhanced and include the forging of new pathways within the developing alliance with General Hospitals, increased ‘visibility’ for training and research opportunities, improved patient satisfaction and improved CQC standing.

This quality improvement project aimed to introduce a staff communication tool, ‘the morning huddle’, to Goddington ward (Green Parks House, Oxleas NHS Foundation Trust). The huddle's purpose was to share key information between members of the ward's multidisciplinary team (MDT) regarding patient risk, diagnosis, mental state and treatment progress.

The project team worked with the Oxleas Quality Improvement (QI) team to create a structured huddle with agreed goals that commenced at 9am each morning. The team sought views from ward staff on the existing communication process before implementing the huddle via a series of weekly questionnaires. The morning huddle was introduced on 26th May 2020 and all members of the team were invited (including the ward consultant, junior doctors, ward manager, nursing staff, healthcare assistants, psychologists, occupational therapist, and ward administrator).

Following multiple PDSA (Plan, Do, Study, Act) cycles, the team further refined the morning huddle into a meeting with a set template that included COVID-19 test results, psychiatric risk concerns, medication adherence, and barriers to discharge. The project team also timed the huddle, aiming for it to last a maximum of 30 minutes. A questionnaire was distributed to ward staff weekly after the huddle was implemented to ascertain their views on the process. Data collection for the project ended on 2nd August 2020.

The project's main outcomes were based on two questions from the weekly staff questionnaire:

1. “How effective did staff members find the morning huddle in addressing their concerns about patients and promoting safety of patients and staff?”

This improved over the course of the project, starting with 20% of staff finding the huddle “good” or “very good” in its effectiveness to 77% finding it “good” or “very good” in the final questionnaire.

2. “How effectively do staff feel that their concerns about patients are addressed by the rest of the team?”

This also improved, starting with 40% of staff selecting “well” or “very well” to 100% in the final questionnaire.

Goddington ward introduced a huddle that was valued by the entire MDT. The huddle improved how well staff felt their concerns about patients were addressed and a noticeable improvement in team morale was observed. While the project succeeded in implementing a huddle that staff appreciated, patient outcomes also need to be considered in future

Evidence suggests that individuals with serious mental illness (SMI) die up to twenty years prematurely compared to the average population without SMI with the main causes of death linked to preventable cardiovascular disease, respiratory failure, and endocrine disorders. This early mortality remains despite national efforts to recognise the issue and promote development of processes to enhance quality of physical health care in patients with SMI. The National Institute for Health and Care Excellence (NICE) clinical guidelines (CG178) recommendation 1.5.3.5 states that healthcare professionals in secondary care should ensure individuals with SMI receive physical health checks from primary care. This idea may be suitable for patients in the community setting or those who undergo shorter hospital admissions, however the process of psychiatric rehabilitation in secure mental health hospitals is challenged by long average stays resulting in no access to routine primary care facilities. The aim of the project is to introduce tailored measures that would aid in delivering high quality physical health care to patients within secure mental health hospitals.

Ravenswood House Medium Secure Hospital supported a project to improve the physical health of individuals with SMI. An audit was completed to evaluate the assessment and management of baseline physical health measures that would have usually been completed in primary care as per the standards set out in NICE guidelines. The results showed that not all measures were being met and there was room for improvement.

Based on these NICE recommendations, an annual health check template and a centralised documentation toolkit were implemented and integrated within a new Physical Health Care Pathway in collaboration with General Practitioners, Dentists, Physiotherapists and other Allied Healthcare professionals.

Following implementation of the Physical Health Care Pathway, the number and quality of annual physical health checks in Ravenswood House Medium Secure Hospital increased resulting in significantly better-quality outcomes for patients by completing appropriate referrals and follow-up care.

This collaborative approach of providing a high-quality physical health care was delivered in-house by arrangement with external healthcare practitioners. This pathway of providing care assisted us in overcoming several challenges faced within secure hospitals due to legal sanctions and related security protocols involving the patient group.