To assess the feasibility and utility of introducing the following changes on to in-patient units:

Structural and cultural adaptation to create a sleep friendly ward environment

A “Protected Sleep Time” between midnight and 6am

Routine screening for sleep disorders, including obstructive sleep apnoea and restless leg syndrome

Insomnia and other sleep disturbances are cause, correlate and consequence of psychiatric disorders. Routine hourly night time observations, ward noise, bright lights at night time, sleep disorders, insufficient exercise, insufficient day light exposure, too much caffeine and inappropriate psychotropic use are all causes of disturbed sleep (Horne 2018).

Seven wards participated in a pilot (SleepWell). These consisted of one male and two female Acute Wards (General Adult), a High Dependency Unit, a Neurorehabilitation ward, an in-patient dementia service and one rehabilitation ward. These wards were supported via an existing trust management structure and the pilot was specifically supported by two trust managers (RW and RB) and by a clinical director (PK). The expectation was that each ward would identify a sleep champion from existing staff to facilitate the changes. A “product” was developed which identified core sleep management features but, in addition, wards were not confined to these. The existing policy that all inpatients should be checked each hour over night was suspended for the pilot wards and the patients had protected sleep time (PST) if the MDT agreed that it was clinically appropriate.

Quantitative and qualitative techniques were used to identify facilitators of change, impact on sleep and, outcome.

Protected sleep was viewed positively by all staff and approximately 50% of patients on the pilot wards were able to have PST at some point in their admission. Routine sleep disorder assessments were harder to implement and 33% of patients were screened. There were no deaths or significant events on patients due to PST. Hypnotic use on the pilot wards reduced. It is anticipated that PST where it is safe will be rolled out across all adult and old age wards in the trust.

With support, it has been feasible to change many aspects of sleep management across a breadth of inpatient units in a large NHS trust.

This Quality Improvement Project aimed to improve physical activity amongst patients in a 16-bedded, low secure unit in the Downshire Hospital, Northern Ireland. We introduced an exercise programme with the aim of increasing minutes of physical activity per week. Secondary outcome measures were weight, mood and energy levels.

This project took place in the context of COVID-19 restrictions having reduced opportunities for off-ward activity and staff noting subsequent deconditioning and weight gain amongst the patient cohort. Cohort consisted largely of patients with a severe mental illness, many of whom had physical health co-mobridities.

This project included all patients in the 16-bedded unit.

Baseline data were collected prior to programme introduction, including weekly activity levels and weights. A questionnaire explored patient confidence and attitude towards physical activity.

Focus groups were held with patients and staff in order to identify how best to introduce the programme, discuss content, and identify potential barriers.

We introduced an eight-week programme of weekly, thirty-minute, mixed ability exercise sessions. These were led collectively by the multi-disciplinary team. Patients actively participated in programme design; choosing session soundtracks and contributing to content planning.

Likert scales were used to measure self-report mood and energy levels pre- and post-session. Staff engaged in a weekly post session de-brief, where challenges were identified and solutions suggested. Weekly qualitative feedback was sought from participants. The sessions were thus developed and adapted according to patient and staff feedback over the programme's course.

Following the 8-week programme, activity levels and weight were re-measured and compared to baseline. Pre-programme questionnaires were also repeated.

Patients reported increased enjoyment and confidence engaging in physical activity, as well as improved overall self- confidence and a sense of pride and ownership of the sessions.

Staff reported a more cohesive team environment, greater sense of work-place fulfilment and improved therapeutic relationships.

Comparing pre and post session ten-point-Likert scales showed a 153% mean increase in self-rated energy levels and a 98% mean increase in self-rated mood. This reflected a mean score increase of 3.8 in both.

Minutes of physical activity per week increased for all session participants, although remained below national guidance.

Weight reduction did not occur.

Exercise benefits not only physical health, but also emotional and psychological well-being. This project demonstrates how introduction of a weekly ward-based exercise class can offer this as well as improving working environment, team cohesion and therapeutic relationships. Weight reduction may be observed in the longer term.

Delivering a new efficient assessment and shorter term secondary mental Health intervention service for individual sectors

In November 2015, there was a transition to services with the focus on delivering more efficient service to clients

Previously we had been a combined sector Service. This transition, a reduction in resources and a move away from delivering care Through specialist mental health teams created from the national service framework - such as Assertive outreach, early intervention in psychosis and community rehabilitation - to a more Streamlined generic service, catering for these differing groups of people using a “Pathways Model” approach

Across the two sectors we had 47 clients on CPA Pathway living in 24 hour residential Settings who all had a current care coordinator.

These 47 clients represented the workload currently of 2.8 FTE Band 6 care coordinators.

There were at Origin, 13 Residential/Nursing/Secure 24 Hour care providers, where clients were residing.

However of these 90% of residents lived in one of 5 settings, 3 settings in Ashfield and 2 in Mansfield.

Over 50% of individuals residing did not have existing connections with Mansfield or Ashfield before being placed into the area.

18 Clients (%38) were under section of the mental health act and 1client (%2) was on a life-Licence from criminal justice.

Transfer of CPA Care Coordination Protocol

To send paper referral to our Single Point of Access Meeting at the listed address at the earliest point relocation/placement is confirmed.Formal handover meeting for care will be coordinated, not sooner than 3 months after the placement commences. It will be expected that services currently involved in provision of service continue to hold care responsibility in the interim period.

As we move to a paperless environment, provision of electronic documentation such has previous CPA documents, Risk assessments, social circumstance reports & Discharge summaries, would be greatly appreciated

To study patients' subjective experiences of having access to a therapy dog and to assess the staff perception of the impact of pet therapy. Hypothesis: pet therapy services are acceptable for rehabilitation patients.

Animal-assisted therapy (AAT) is the supervised use of an animal in a therapeutic setting to help in the treatment of physical or psychological disorders in humans. The use of dogs in the context of AAT - ‘dog therapy’ (DT) - has been piloted in the context of stroke rehabilitation; schizophrenia in elderly patients; depression, loneliness and anxiety in elderly patients; Alzheimer's disease; symptom reduction in PTSD; cognitive impairment; and dementia. The impact of pet therapy in long term psychosis care has not been adequately assessed.

This feasibility pilot study used questionnaires to assess patient (n = 12) and staff (n = 10) perceptions of dog therapy in an in-patient psychiatric rehabilitation setting. 24 patients on a rehabilitation ward with complex psychosis were offered the opportunity to interact with ‘Nugget,’ a corgi trained in the United States as a ‘therapy dog.’ A ‘patient questionnaire’ (PQ) and a ‘staff questionnaire’ (SQ) assessed the acceptability and self-rated benefits of the intervention.

All patients (100%) rated highly on the enjoyment, anxiety, calmness, and comfort domains during the dog therapy, and expressed willingness to receive further sessions in the future. The SQ measured staff perceptions of patients’ engagement, enjoyment, comfort and emotional response to the therapy. 100% of staff rated highly on all questions and thought the interventions had recovery value. Engagement was one key factor noted in the feedback. There were no reported adverse reactions to the intervention.

Our preliminary results showed high acceptability and perceived value for Animal assisted therapy in a psychiatric rehabilitation setting. Given the impact of social isolation and need for connectedness, we recommend access to pet therapy where possible to be integrated into individual recovery programmes.

Physical health monitoring is paramount to optimal care for psychiatric patients. Blood tests and ECGs are invaluable tests throughout a patient's care. At baseline, they aid investigation of potential organic causes of psychiatric presentations and provide organ and electrolyte status before starting medication. Common psychotropic medications carry physical health risks: bloods and ECGs aid in monitoring potential side effects of prescribed medication.

In this local Tier 4 inpatient unit, anecdotal observation revealed completion of these basic investigations was noted to be suboptimal.

This project aimed to improve timely completion of baseline (within 72 hours of admission) and monitoring (within one week of due date) bloods and ECGS.

This project was completed within a 12-bed child and adolescent inpatient unit. Using Plan Do Study Act (PDSA) methodology, the multidisciplinary team collated driver diagrams to identify potential areas for intervention. Following baseline analysis, colleague communication was considered key. Consequently, a chart for bloods and ECG completion was created.

Each monthly PDSA cycle included the following consecutive interventions:

• PDSA cycle 1: chart implementation

• PDSA cycle 2: chart simplification and font size increase

• PDSA cycle 3: allocated change in team leader for this cycle

• PDSA cycle 4: Blood request pocket in office

• PDSA cycle 5: chart simplification through removal of dates

• PDSA cycle 6: ECG pocket

• PDSA cycle 7: box on handover list

Monthly investigations and admission numbers are unpredictable and inconsistent in this cohort: relevant case numbers per PDSA ranged from zero to ten. The results were presented as percentages to allow for direct comparison between cycles.

Baseline and results of each consecutive PDSA cycle described above were as follows (N/A represents a cycle where no investigations were required):

Admission bloods were completed within 72 hours in 50%, 100%, 50%, 80%, N/A, 100%, 100%, 100%

Admission ECG was completed within 72 hours in 30%, 66%, 50%, 70%, N/A, 100%, 100%, 100%

Monitoring bloods were completed within one week of due date in 25%, 33%, 0%, 80%, 100%, 100%, 100%, 100%

Monitoring ECG was completed within one week of due date in 0%, 0%, N/A, 66%, 100%, 66%, N/A 100%

Through close multidisciplinary collaboration and chart implementation, completion of bloods and ECGs improved. Low patient numbers per PDSA cycle resulted in large changes in percentage results, limiting the significance of these findings. Wider implementation of the chart within local Trust inpatient wards is considered.

Violent or aggressive incidents can be relatively common in community settings, and perhaps more difficult to manage than at inpatient wards due to the relative isolation and peripatetic delivery model, which can put staff at higher risk during incidents. Carshalton and Wallington Recovery Support team was identified as an outlier in the Trust and was invited to partake in a Safety Collaborative across South London Partnership.

Stakeholders agreed on the aim of reducing incidents by 20% over 1 year by the end of 2020.

Data about incidents were analysed and staff surveys conducted to evaluate violent events. Patient discharge was highlighted as a particular time of increased aggression. Involvement of patients and carers through patient focus groups and co-production was essential to elicit areas of improvement. These included staff confidence and awareness of existing guidelines. Additional secondary drivers were communication with patients, care pathway development, discharge process and multidisciplinary approach, which each had associated change ideas.

The team identified change ideas that have been tested over one year using the Quality Improvement methodology of small-scale testing and PDSA. Example ideas tested include multidisciplinary Risk meetings, Safety huddle tool, Staff Safety training, co-produced Welcome and Discharge Packs with informed care pathways.

There has been a 30% reduction in incidents by December 2020 across a total of 280 patients. Surveys have shown an increase in staff confidence and safety protocol awareness from 40% to 70% by October 2020. 100% of patients in focus groups found the Welcome and Discharge Packs helpful.

A structured improvement approach focused on staff safety and minimisation of known and potential contributing factors can lead to a reduction in incidents. Safety huddles and risk meetings allow a formal multidisciplinary approach to management of violence and aggression. Staff feel more reassured about safety policies in the trust, with better communication between senior management and colleagues to highlight risk and provide support. A culture of open discussion and transparency was implemented through provision of Welcome Packs including Care and Discharge Pathways details at point of entry to the service. Support was provided to patients with Discharge Packs including information about community services. This enabled a meaningful support model at the end of their recovery journey and an improved discharge process.

The team is now working with additional teams and administrative and clerical staff to improve safety. We hope to replicate this approach in our Trust.

Hospital Electronic Prescribing and Medicines Administration (HEPMA) system successfully rolled out in July, 2020 at the Orchard clinic as the first site in NHS Lothian. The initial aim was to collect some “pre-HEPMA” and “post-HEPMA” data to look at “staff's attitudes to a new IT system, and does that change with successful implementation of it?” in the form of a survey. In the light of the findings of the pre-HEPMA staff survey, it became the QI project (as above).

This aimed to look at both qualitative data; in the form of a staff attitudes survey towards a new IT system and quantitative data; to measure benefits of its implementation and to address issues raised by staff in the survey in the form of an audit in both pre and post HEPMA cycles.

Two cycles were completed as follows:

1. Pre-HEPMA cycle in March, 2020:

Survey: Questionnaires asking question re- own IT skills, preparation and expectations of outcome of its implementation.

Audit: Measured time taken to write and re-write paper prescriptions. Proforma filled by staff to measure time taken to log on and other IT related issues.

2. Post-HEPMA cycle in October, 2020:

Survey: Replicated above questions re-own IT skills, support during and after launch, disaster recovery and views about actual outcome of its implementation.

Audit: Replicated to measure time taken to complete electronic prescriptions.

24 staff questionnaires returned in both cycles. Staff felt more confident in their own IT skills, training and hence competence to use HEPMA; more supported, more confident about contingency plans and HEPMA to be more beneficial than initially anticipated. Overall, actual perceived success of (91%) compared to anticipated success (71%).

The majority issues raised via the first survey were felt to be addressed. Time to log was on average

The audit showed a clear benefit in terms of clinical time saving, e.g. daily clinical time spent writing prescription reduced from an average 45 to 6 minutes with HEPMA.

The quality of documentation on the prescriptions remained unchanged.

Staff's attitude towards IT does change after successful implementation of a new IT system. But IT issues make the whole process laborious.

There was evident benefits realization with an electronic prescribing system compared to paper prescriptions.

I was awarded “Employee of the month” for this project which I also presented at the NHS Lothian grand round (>150 attendees) for dissemination and future replication.

Devon continues to see increasing numbers of rough sleepers despite the “Everyone In” initiative and the South West region is now behind only London and the South East nationally. The interaction of homelessness and Mental Health is complex. Mental health problems and trauma contribute to people becoming homeless as well as homelessness itself causing or exacerbating existing problems, all complicated by high rates of substance use and poor physical health. Despite the desperate need in this population they often struggle to access mental health services which are not designed with their needs in mind. Their pattern of service use is primarily that of acute services when in crisis and disengagement in the community which results in high costs and poor outcomes.

In July 2019 an outreach service was set up consisting of a psychiatry core trainee (Dr Tom Scott-Gatty) for half a day per week supervised by the Torbay North CMHT consultant (Dr Tom Cant) to seek opportunities to engage individuals in assessment and treatment and improve outcomes in this population. The service is primarily based at the homeless hostel in Torquay (Leonard Stocks Centre) for ease of access but is flexible about where patients are seen. Patients have been seen in various locations including medical wards, prison, on the street etc. The role includes close work and liaison with other professionals such as GPs, probation, charity sector, drug and alcohol etc. and this is integral to supporting the level of complexity seen in this population. Engagement, building relationships and trust are central to serving this vulnerable and marginalised population.

In January 2021 feedback forms were completed by 13 patients and 18 professionals who had used the service. Feedback was overwhelmingly positive with average overall score 9/10 from both patients and professionals. All patients reported feeling comfortable using the service and that mental health services are now easier to access. All respondents would like to see the service continue. A significant number of patients and professionals identified increasing the hours offered by the service as an area for improvement.

This service has succeeded in improving access to mental health services for homeless people in Torbay. The service is valued by both the people it serves and the professionals supporting them. Further improvement to the service could be achieved by expanding capacity. Funding has been identified from existing local authority budgets to add a CPN to the team to achieve this.

To establish the improvements in the quality of seclusion medical review after introducing a template to complete the review.

The Mental Health Act – Code of Practice outlines the standards of patient care while in seclusion. It also emphasis that supportive engagement/observation schedules should be reviewed in person and continued at the point an episode of seclusion was initiated.

Furthermore, NICE also set up standards to monitor side effect profile while prescribing psychotropic for such patients and regular management review. It also gives importance to staff training to ensure these standards.

To improve the quality of the seclusion medical review, we completed an audit in July 2019 to ascertain whether medics are following Trust Policy.

We identified good results (above 90%) in the following areas:

Time of seclusion review

Record keeping

Management plan

Good documentation of risk, mental state examination and physical health.

We also noticed that the following areas can be improved:

Prescribed Medications. (60%)

Medication side effects. (40%)

Physical Observations (40%)

We used the following audit standards for our audit after our last audit and a template was designed and after discussion with medics incorporated into the existing documentation template.

Time of review

Reason and duration for seclusion

Psychiatric diagnosis

Mental State Examination/Behaviour

Physical health (including physical observations)/Environment

Medication (prescribed, rapid tranquilisation, side effects, or adverse effects)

Risk (to self-DSH or accidental) (risks to others)

Plan :(frequency of physical obs./medical review, management, restrictions, exit plan for terminating seclusion, patient's capacity to understand it)

We considered the following aspects:

Retrospective data collection from 01.03.2020 to 30.08.2020.

Sample selection: random selection of mixture of clinicians on different times and days of the week.

Data analysis was carried out by using Microsoft Excel.

We noticed a marked improvement in the quality of seclusion medical review (between 95% and 100%) after introducing a template for it. There were no major concerns identified during the re-audit.

To continue to use the template for Seclusion Medical Review which has shown significant improvement in the quality of the reviews which will improve patient care.

It also helped us to deliver person centred care and safe practice.

To continue teaching and training of doctors.

This QIP project motivated nurses to do an audit on nursing seclusion review and made necessary changes.

We accessed whether medics are following Trust Policy while conducting seclusion medical review and identify the strengths in quality of seclusion medical review and identify the areas which need improvements to improve our quality and standards of patient's care and safety and to reduce risks.

The Mental Health Act Code of Practice sets an expectation for mental health services for restrictive interventions (use of restraint, seclusion and rapid tranquilisation) by following good standards. Medical reviews provide an opportunity to evaluate and amend seclusion management plan. This clinical audit was undertaken by looking at quality of record keeping about seclusion review by junior doctors, staff grades and consultants at different times (day, night, and weekend).

Data analysis was carried out by using Microsoft Excel. The audit had Humber Teaching NHSFT approval. We assessed electronic healthcare records. Data collection was carried out or retrospectively in 2019(n = 40) using following parameters:

1. 1) A review of patient's physical and psychiatric health.

2. 2) An assessment medication prescribed and adverse effects of medication.

3. 3) A review of observations required.

4. 4) An assessment of the risk posed by the patient to others.

5. 5) An assessment of any risk to the patient from deliberate or accidental self-harm.

6. 6) An assessment of need for continuing seclusion, and whether it is possible for seclusion measures to be applied more flexibly, or in a less restrictive manner.

7. 7) Time of Seclusion Review: Within first hour after seclusion and then every 4 hours until internal MDT. After MDT twice a day.

8. 8) Record Keeping.

Key Successes (above 80%)

Time of seclusion review (with in first hour or when required)

Record keeping (accurate time and place for clinical notes).

Plan for continuing need for seclusion.

Good documentation of Risk to self and risk to others.

Good documentation of mental state examination.

Comments on physical health although it can be improved.

Key Concerns(Less than 60%):

Prescribed Medications.

Medication side effects.

Physical Observations

Medics are missing some important parts in seclusion medical review. We developed a template for seclusion medical review according to trust guidelines which are based on Code of Practice and to incorporate in already existing seclusion review form. We also delivered teaching and training to doctors and also showed junior doctor's an example of documentation. We will re-audit in 1 years’ time to see improvement.

To improve communication with patients and carers by sharing information in an easily comprehensible manner.

According to the department of health guidelines, there is legal requirement to provide copies all clinical correspondence to the patients. Therefore, after any clinic review, letters summarizing the consultation are sent out to GP and patients are copied in. However, these are not very meaningful for patients with special needs, as they struggle to comprehend information. Previous studies have shown that patients with learning disability would prefer letters in a simple language and would also like to participate in the decision making process. According to Accessible Information Standard, we have a legal obligation to deliver information to our service users in an easily understandable manner. We undertook a quality improvement pilot project of easy read templates to improve the understanding of patients and their carers/families.

A standard easy read template was co-produced after collecting feedback from different service users and clinicians. Pictures were incorporated into the questionnaire to facilitate understanding. We collected reviews over a period of 2 months from Nov 2019- Dec 2019. This proforma did not replace the routine clinic letter send out to the GP and the patients. This easy read template began with the introduction of the doctor (with photograph) and it encompassed mental health, physical health, current medication (and the benefits and side effects if any) and changes of medication. It also included epilepsy and the risks (risks to self and to others), vulnerability, behaviours of concern and the day-to-day activities that a service user engages in and finally about the plan formulated at the end of the consultation. At the same time, there was a separate form (with self-explanatory pictures), which collected feedback about the above mentioned appointment outcome review form.

Templates were handed out to 65 patients and carers, and 60 completed the form. All patients found the template useful and helpful, mainly because it was easily comprehensible, with pictures, and also “provided instant updates”.

This easy read template improves patients’ understanding and participation in the clinic review. This contributes to greater patient satisfaction. As Specialist Learning Disability services, we need to ensure that information is imparted to the patients and the carers in an easily understandable manner and this easy read template should be incorporated in the routine clinic practice.

Analyse the pattern of psychotropic drug use and deprescribing (in the context of STOMP) in people with Intellectual disability and Challenging behaviour in Hertfordshire community team(s) during 2016-17. STOMP stands for Stopping Over Medication in People with Learning Disability, Autism or both.

Public Health England in 2015 estimated that on an average day in England, between 30,000 and 35,000 adults with a learning disability, autism or both were taking prescribed psychotropics without appropriate clinical indications . HPFT signed up to the STOMP pledge in 2017 to actively review psychotropic prescribing in line with NICE guidance alongside patients, carers and professional partnerships. This audit provides the outcomes of applying the STOMP Pledge to clinical practice.

Data collection for the current audit occurred over Q1-5 in 2016–2017. All patients with Intellectual Disabilities on psychotropic medication were reviewed in psychiatric clinics. Awareness was raised about STOMP in teams. A semi-structured tool was developed based on the Self assessment framework published by the ID faculty RCPsych and prospective data were collected after each outpatient visit.

347 patients were prescribed psychotropic medication and reviewed quarterly between 2016-2017. 96 patients were prescribed antipsychotics for challenging behaviour. Other prescribed medications included mood stabilisers, anticonvulsants, anti-depressants and benzodiazepines. Common antipsychotics used: Risperidone (63), Aripiprazole (14), Quetiapine (9), Olanzapine (4); Chlorpromazine (2). Four patients were maintained on two antipsychotics in varying combinations. The data collection tool noted that alternatives to medication were tried in 32 cases. Deprescribing occurred in 41 cases

This study represents an attempt to capture the impact of the STOMP principles in a clinical sample. Various alternatives to medications were pursued in the sample such as positive behaviour support, sensory integration, psychological therapies, social support. Younger adults (under 30 years) represented the largest proportion of cases where medication was increased. Adults over 30 years represented the largest proportion of cases where a STOMP reduction occurred. This may reflect the individual factors at play. Younger people with ID and /or Autism are more likely to experience changes in support and structure at transition, whilst older adults may have more physical comorbidities that may influence this decision.zcvv

The current audit aims to identify the gaps in the practice of administering prn buccal midazolam, for management of epilepsy in people with intellectual disability and to review training needs, with a view to improve patient care.

Convulsive status epilepticus is a medical emergency requiring admission to hospital and has a mortality as high as 20% (SUDEP -Sudden Unexpected Death in Epilepsy). It is imperative that the carers are fully aware of the risks associated with the epileptic attacks, are able to recognize the attacks and offer rescue medication to the patient in a timely and effective manner. National guidelines have been drafted jointly by ESNA (Epilepsy Specialist Nurses Association) and ILAE (International League Against Epilepsy) for prn administration of buccal midazolam. The use of rescue medication by trained carers can significantly improve the outcome and reducing the risk of hospital administration and chances of SUDEP. Buccal midazolam is widely used to manage prolonged seizures. Administration should be undertaken only by people who have received both epilepsy awareness and buccal midazolam training.

All patients with intellectual disability with epilepsy were studied and patients who were prescribed prn midazolam have been shortlisted shortlisted for data analysis. A template was designed and data are being collected from the carers, community nurses and the prescribing clinicians. Data are categorized under headings of background information about epilepsy, recognizing complications during a seizure and the ability to administer buccal midazolam. Further information about the type and the frequency of training courses (including the refresher courses) being offered to the carers for administration of buccal midazolam would also be documented. There is also data collection pertaining to the timely review of the care plan by the prescribing clinicians and the about the licenced or unlicensed used of midazolam. The quality of epilepsy awareness training is being explored in depth and also the competency of the county council nurses offering the training to the carers shall be analysed under different headings.

Data are currently being collected in Hertfordshire and Essex mental health services.

After the data analysis, the short comings shall be addressed and effective measures shall be put in place to improve the quality of training being provided to the carers and to standardise the practice for prn midazolam prescription.

This quality improvement project aimed to assess the adherence of a hospital psychiatric liaison team's documentation of assessments to the Psychiatric Liaison Accreditation Network (PLAN) standards framework; to identify areas of improvement; to identify barriers to and improve adherence.

Data were extracted from 27 randomly selected patient assessments from 01/07/2020 to 31/08/2020 and then 27 assessments from 01/10/2020 to 30/11/2020 for re-audit.

Quantitative data was collected by calculating the percentage of assessments which documented each specific aspect of PLAN standards.

Qualitative data including attitudes specifically towards writing to patients was gathered from 1:1 discussions with members of staff.

Interventions between rounds of audit:

Presentation of results of 1st data collection to team in November 2020 followed by discussion

Emailed instructions to create a template based on PLAN standards for assessments to staff

Lobbied for Cerner access at liaison team office to facilitate use of above

Quantitative – overall improvements were seen in adherence to all aspects of documentation of assessments including collateral history (from 23% to 67%) past medical history (30% to 70%) and acknowledging the patient/carer perspective (46% to 74%). Some improvement was seen in offering written correspondence to patients (0% to 20%).

Qualitative – the majority of comments regarding writing to patients were positive, with no staff members opposing the standard (“it is best practice”, “should become a habit”). However, some barriers were identified including increased workload (“requires more editing”, “could take a lot more time”).

Team adherence to PLAN standards for documentation of assessments was improved through low intensity interventions. Overall adherence was high, however certain areas leave space for improvement. The audit facilitated conversations around writing to patients on discharge, both in the form of formal gathering of qualitative data and informal discussions between staff. Attitudes towards writing these letters were positive and some improvement was seen between audits. Ongoing audit activity aims to further improve adherence and monitor improvements.

The aim of this study is to identify the prevalence of pulmonary disease or progression of symptoms which can lead to respiratory disease in substance misuse. Identify risk: prescribe a safer substitute treatment (Methadone vs Buprenorphine). Identify combination of different drugs, causing toxicity and damage to lungs.

Smoking and illicit substance misuse is recognized as a cause of pulmonary disease

The study was conducted in 2015 at outpatient addictions service (CAPS/CDC 69 Warwick Road London SW5 9HB). All 50-participants gave consent and data were collected including demographic details, history of substance abuse, route of administration, medical history, Peak Expiratory Flow rate (PEFR). A questionnaire was designed to assess the severity of shortness of breath (SOB), with or without exertion to ascertain the extent of the disease.

14 males and 3 females achieved 31 to 48.9 % of predicted PEFR. 13 males and 7 females achieved 51.1 to 69.6% of predicted PEFR. 7 males and 2 females achieved 70.8 to 91.1% of predicted PEFR. 2 males and 2 females achieved 100 to 114.3% of predicted PEFR. From the questionnaire on SOB with or without exertion, 8 males and 2 females reported moderate to severe shortness of breath on minimum exertion. 33 males and 11 females reported variable degree of SOB. 4 males and 2 females did not report SOB on reasonable exertion. 23 males and 10 females reported variable degree of SOB at rest, 14 males and 3 females reported no SOB at rest. 34 participants were receiving OST with methadone, 16 were on Buprenorphine. 6 patient treatments were switched to Buprenorphine due to Exacerbated COPD. 47 patients reported using Tobacco from harmful to dependent use. 44 patients reported harmful to dependent use of crack cocaine. 34 patients fulfilled the criteria of harmful use of cannabinoids. 33 patients were diagnosed with harmful to dependent use of alcohol. 10 patients reported heavy use of solvents. 2 patients reported harmful use of Party drugs. Many patients reported a history of recurrent chest infections 3-6 times a year, Asthma, COPD, Emphysema, Pneumonia and 2 were treated for Tuberculosis. 1/3 patients have a diagnosis of hypertension and IHD, liver disease and portal hypertension

To reach 80% adherence to DVANI (Driving and Vehicle Agency Northern Ireland) guidance in acute inpatients ward, T&F Hospital

This is a scale-up of a previous successful QI project on driving and Attention Deficit Hyperactivity Disorder in Belfast Trust. According DVLA's guidance for medical practitioners on the current medical standards of fitness to drive, patients with certain mental health diagnosis are required to inform DVLA of their diagnoses and refrain from driving. Different factors are considered in order to determine patients’ fitness to drive. According to DVLA and GMC, it is medical professionals’ responsibility to advise patients to inform DVLA/DVANI of their mental health diagnosis. It is the patient's legal duty to notify DVLA/DVANI of their diagnosis. Patients can be fined up to £1000 if they failed to inform DVANI of their medical condition.

Outcome: Completeness of driving advice given to consecutive patients discharged from T&F hospital from April 2019 to early August 2019 in %

Process: Document clearly in electronic and written notes on following - (1) has driving status been asked (2) has patient been advised to inform DVA if required (3) has patient been advised likely how long he/she is to refrain from driving for

Balancing: increased the time of reviews, increased numbers of consultant reports requested from DVA

4 cycles have been completed. Cycle 1 – baseline and review guidance; Cycle 2 – medical staff education and developed driving advice pathway and patient leaflet; Cycle 3 – admin staff was involved for putting driving advice pathway in admission pack; Cycle 4 – medical staff was educated again regarding importance of documenting electronically. Clear changes were seen after cycle 3 showing an increase of mean of 25% completeness of driving advice to over 90%.

It is the legal duty of patients to notify DVANI of mental health diagnosis, however it is the responsibility of medical professionals to advise patients to do so. This QI project has shown improvement in the completeness of driving advice given. Further cycles are to be completed to obtain patient feedback.

To attempt to quantify the use of seclusion and restraint for young people managed by the NHS Lanarkshire CAMHS Learning Disability team.

There has been increasing interest in the use of seclusion and restraint in children with learning disabilities, reflected by various news reports in the UK and USA. A survey of parents conducted by the Challenging Behaviour Foundation (2019) found that 35% of disabled children (n = 204) had been regularly physically restrained and a further 21% had been regularly secluded. The use of restrictive practice in children is contradictory to the UN Convention on the Rights of the Child as well as the conclusion of a recent report conducted by the Scottish Children's Commissioner titled “No Safe Place” which called on schools to stop using restraint and seclusion until national guidelines and standards were in place. No data were submitted to the Children's Commissioner from Lanarkshire. Anecdotally there was an impression in the team that restrictive practices were widely used at school and home.

The NHS Lanarkshire CAMHS-LD team is a small team caring for children aged 5–18 years with moderate to severe/profound learning disability with mental disorder and/or severe challenging behaviour. The methodology for this retrospective audit relied on reviewing patient case notes and speaking with involved clinicians. We discussed each individual patient on their respective caseload as to whether the child had been restrained or secluded at home or at school.

All 108 children from the caseload were included in the audit of whom 52.8% had been either restrained or secluded. 24.1% of children were both restrained and secluded at school, while 15.8% were restrained and secluded at home. These patients were complex. 86.1% had Autistic Spectrum Disorder and 55.6% had another comorbidity, such as ADHD.

The figures are broadly similar to those in the Challenging Behaviour Foundation report. The team knew all of the individual patients very well and review them across a variety of settings such as school and home with instances of seclusion and restraint being directly witnessed by clinicians. Nevertheless, there is the issue of recall bias. These findings will be shared with NHS Lanarkshire management for further discussion and dissemination. .

This project aimed to improve adherence to regular monitoring of the physical health of inpatients within a medium secure forensic psychiatric unit. A computerised tool to remind doctors to do checks was created, which was proposed would improve adherence.

The physical health of people with mental health problems is of some concern, with higher rates of physical comorbidity and mortality compared to the general population.

The forensic inpatient population has a high burden of both severe mental illness and physical ill health, and a high medication burden with potential adverse effects on physical health.

To support the health of patients in our medium secure unit, each should routinely have three physical health checks done at least every six months. These are 1) an electrocardiogram (ECG), 2) a set of blood tests and 3) a full physical examination.

Patient records for 26 patients across two medium secure psychiatric wards were checked for 1) an ECG, 2) a full set of blood tests and 3) a full general physical examination within the past 6 months.

A tool was created that automatically calculated the next due date for each check and colour coded which were overdue (red) or within 30 days of the due date (yellow). This tool was given to the core trainees working on these wards to help them keep track of which checks needed to be done.

The records for patients on the same two wards were rechecked four months later and the adherence rates compared.

On both wards, for each of the three physical health checks, a substantial improvement was seen in the proportion completed within the past 6 months.

The tool created was a useful means of presenting, in one place, relevant information needed by doctors working in medium secure forensic wards regarding physical health checks, and drawing their attention to tasks that needed to be done. This led to an improvement in the adherence to physical health monitoring in these wards. An area for future improvement was identified regarding the unit's capacity to perform ECGs in a timely manner.

The aim was to improve the experience of transgender patients in a general adult inpatient setting, through delivering practical 'bitesize' ward-based staff training. This training was to improve awareness of issues faced by transgender patients, knowledge around gender dysphoria, and increase confidence in discussing these issues appropiately with patients.

Staff from a range of disciplines attended sessions held on the ward in small groups; these bite size sessions were delivered in under 20 minutes making them easy to fit around clinical commitments.

All attendants rated increased confidence in their skills and ability to support transgender patients.

Improved staff training specifically focussing on transgender patients can contribute towards improved care for this patient group; this should form part of a wider strategy including clear operational policy and supportive environments.

To improve the one hour response times to referrals made to psychiatric Liaison in A&E without adding or changing available resources.

Response time data of referrals made to the Homerton University Hospital psychiatric liaison service was collected dating back from August 2016 to October 2019 (n = 10225).

A nudge was introduced in the form of a large display showing referrals arriving in real time in the staff office.

Data was then collected over a period of 5 weeks (n = 436) to measure if any change had occurred in response times.

Response times appear to follow a Poisson like distribution curve. The average referral was responded to within 6 minutes (n = 1577) prior to the nudge, and 6 minutes (n = 88) after. Prior to the nudge the 95% referral envelope fell within 134 minutes (n = 9728) and was 122 minutes (n = 414) after the intervention. Significant statistical difference is observed upon considering response in the first 240 minutes.

Nudge interventions could be a useful resource-sparing method to improve services. The average referral to the HUH liaison team was quickly responded to within 6 minutes and yet hitting the 1 hour 95% target appears ever-elusive. Hitting targets of 95% responses within 1 hour may prove very difficult if we are not considering natural distributions, such as Poisson, occuring in the backgroung which ultimately may require a change in approaches to how we set performance targets.