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Contents List of Recommendations ...... 5 Introduction ...... 6 Why we did this themed visit ...... 6 What we expect from a rehabilitation service ...... 7 How we carried out visits ...... 9 General findings – how many people etc ...... 9 Key findings ...... 10 Recommendation one ...... 10 Staff and team resource...... 11 What we expect to find ...... 11 What we found ...... 11 Nursing ...... 11 Training and Supervision ...... 12 Care Plans ...... 13 What we expect to find ...... 13 What people told us about their care plans ...... 13 What we found in the care plans ...... 14 Focus on rehabilitation ...... 14 Care plans ...... 15 Risk Assessment ...... 17 Evidence of reviews ...... 17 Physical Healthcare ...... 18 What we expect to find ...... 18 What we found: ...... 19 Annual physical health checks ...... 19 Screening in line with national screening programmes ...... 19 Management of physical health conditions ...... 20 Care planning and treatment for chronic physical health issues ...... 20 Treatment available for patients to address alcohol/substance misuse issues ...... 22 Support/arrangements in place for people who smoke ...... 22 Recommendation two ...... 24 What people told us about exercise ...... 25 What people told us about their weight and weight management ...... 25 Treatment with medication for mental health conditions ...... 27 What we expect to find ...... 27

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What we found ...... 27 Medication reviews ...... 29 Authority for treatment under the Mental Health Act ...... 29 Recommendation three ...... 30 Diabetes and Clozapine ...... 30 Rights and Safeguards ...... 31 Advocacy, advance statements and the management of funds ...... 31 What we expect to find ...... 31 What we found ...... 31 Detained patients ...... 31 Helping patients understand their rights ...... 31 Advocacy ...... 31 Advance Statements ...... 32 Recommendation four ...... 33 Management of funds ...... 33 Activity and recovery ...... 36 What we expect to find ...... 36 What we found ...... 36 Activity planners ...... 36 Activities ...... 37 Opportunities to leave the ward and access outside space on a regular basis ...... 38 Things patients would like to do but do not get the chance to do ...... 39 What community services do individuals access? ...... 39 Peer support ...... 40 Carers’ involvement ...... 41 What we expect to find ...... 41 What we found ...... 41 Environment ...... 43 Delayed discharge ...... 44 Recommendation five ...... 44 Conclusion ...... 45 References ...... 46

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List of Recommendations

1) NHS Boards should consider seeking accreditation under the AIMS standards for in- patient mental health rehabilitation services, or benchmark their service against these standards, with particular attention to factors such as: a) Delivery of physical healthcare b) Participation in purposeful and meaningful therapies and activities which reflect the preferences of patients c) Evaluation of outcomes using structured measurement tools.

2) NHS Boards should ensure that no-smoking perimeters they have set around buildings are clear to patients and staff, and that patients are supported to comply with no smoking policies.

3) NHS Boards should ensure that processes are in place at ward level to audit the prescription of medication for detained patients and the certification of this under Part 16 of the Mental Health (Care and Treatment) () Act 2003, to ensure that all such treatment is properly authorised.

4) NHS Boards should develop plans to promote the knowledge and use of advance statements in rehabilitation services.

5) Integrated Joint Boards should review on an individual basis rehabilitation patients whose discharges have been delayed by over 3 months in order to develop a clear plan for discharge within an acceptable timescale.

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Introduction The Mental Welfare Commission regularly visits providing psychiatric care. We carry out local visits to look at the experiences of people receiving treatment in these wards, and we publish these local visit reports on our website. We also undertake themed visits, where we visit people using similar services across a short period of time, with key questions for patients, staff and visitors.

In this visit we focused specifically on NHS in-patients in rehabilitation services. The function of a specialist inpatient rehabilitation service is to help patients gain or regain the skills and confidence needed to progress their recovery. Inpatients in rehabilitation services are likely to have severe and complex mental health needs and will often have spent months or years in hospital which significantly affects their skills and abilities needed to live back in the community.

Since 2011 the number of rehabilitation beds had decreased from 421 to 309. We visited 130 patients. We did not include patients in continuing care beds since we felt this was a different patient group. Why we did this themed visit This themed visit was arranged because it is some time since we looked at rehabilitation, which is an important element in the spectrum of mental health services. Over the past 16 years we have undertaken a number of themed visits to look at the mental health care and treatment of people in relation to rehabilitation:

• In August 2003 we published Greater Expectations1 which reported on our visits to 350 patients across 18 continuing care and slow stream rehabilitation wards for people with severe and enduring mental illness. We saw large institutional wards where patients slept in dormitories with limited personal possessions and personal space. We also found a lack of reviews of care and treatment. There was a lack of activities or community engagement for patients. • In Greater Expectations Revisited (2009)2 we reported on a series of visits to 159 people in rehabilitation and continuing care wards. We found that some patients were spending more time out of hospital, and more were now attending reviews, and being involved in care planning. However, ward environments had not improved and were unfit for purpose. We recommended NHS boards set admission criteria for wards in order to prevent the emergence of resident groups with widely disparate mental and physical health care needs. • In Living with severe and enduring mental illness in Scotland (2016)3 we interviewed 59 people who were living in the community, and were receiving care, treatment and support from community mental health services. Generally individuals living in the community were positive about the level of support they received from professionals.

1 Mental Welfare Commission for Scotland (2003) Greater Expectations https://www.mwcscot.org.uk/sites/default/files/2019-06/Greater%20Expectations.pdf 2 Mental Welfare Commission for Scotland (2009) Greater Expectations Revisited 2009 https://www.mwcscot.org.uk/sites/default/files/2019-06/Greater%20Expectations%20revisited%202008.pdf 3 Mental Welfare Commission for Scotland (2016) Living with severe and enduring mental illness in Scotland https://www.mwcscot.org.uk/sites/default/files/2019- 06/living_with_severe_and_enduring_mental_illness_in_scotland_report_final_2.pdf

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They felt listened to, having a consistent person to engage with, and felt that services were responsive with supports increased when necessary.

In comparison with acute inpatient services where the length of stay is short (averaging 40 days in the inpatient census for Scotland) the length of stay for people in rehabilitation services is much longer (582 days) and a higher percentage are likely to be detained under the mental health act (73% of patients in rehabilitation wards compared with 43% in acute psychiatry wards.4 Given these differences and the impact on people of being in hospital for a prolonged length of time, we wanted to visit all rehabilitation services to review the standard of care in these wards and to hear from patients about their experience of being treated in a rehabilitation service.

We visited 22 wards in 15 hospitals between June and September 2018 and met every patient who was able and willing to talk to us. We spoke with staff, and reviewed case files and drug prescription sheets, including those of patients we had not been able to talk with.

We also spoke to 26 family members to find out their experiences of the care and treatment of their relative. What we expect from a rehabilitation service Over the past decade hospital inpatient bed numbers for the treatment of people with mental health conditions have decreased considerably across Scotland5 in keeping with service changes across the UK. The reduction has applied to all types of inpatient beds and has been accompanied by an increase in spend on community mental health services.6 While many people continue to benefit from these changes, which can be experienced as shorter admissions to hospital and greater support when out of hospital, some people at points in their life require longer spells in hospital and further specialist help to achieve the best recovery possible for them.

Rehabilitation services are most associated with this process of helping people achieve the best functional recovery they can. There are different definitions of what makes a service or inpatient mental health ward a ‘rehabilitation service’. Although all inpatient wards will have a focus on recovery7 we like the Royal College of Psychiatrist’s definition of a ‘rehabilitation service’:

“A service to help people recover from the difficulties of longer-term mental health problems. It will help and support people who still find it difficult to cope with everyday life or get on with other people. It will aim to help individuals deal with problems, to get confidence back, and to help them to live as independently as possible.”

4 Scottish Government Annual Inpatient Census 2019 https://www.gov.scot/publications/inpatient-census-2019-part-1-mental-health-learning-disability- inpatient-bed-census-part-2-out-scotland-nhs-placements/pages/5/ 5 National Adult Mental Health Benchmarking Project 2017/18 https://www.isdscotland.org/Health-Topics/Quality-Indicators/National-Benchmarking- Project/Mental-Health-Dashboard.asp 6 National Adult Mental Health Benchmarking Project 2017/18 https://www.isdscotland.org/Health-Topics/Quality-Indicators/National-Benchmarking- Project/Mental-Health-Dashboard.asp 7 Refer to recovery definition at Recovery Network https://www.scottishrecovery.net/what-is-recovery/

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Rehabilitation services are commonly led by Consultant Psychiatrists whose training may have included an ‘Endorsement’ from the Royal College of Psychiatrists indicating that they have interest and expertise in the treatment of people using a rehabilitation model of care. They work closely with a multi-disciplinary team.

When people are treated in a rehabilitation service we would expect that they have access to a multi-disciplinary team that has the requisite skill mix to deliver care that is focussed on rehabilitation.

In addition to the skills of psychiatrists and mental health trained nurses, there should be input from occupational therapists, clinical psychologists and primary care specialists or other doctors competent in overseeing the management of physical health co-morbidities. Rehabilitation teams should also have formalised access to input from dieticians, physiotherapists and speech and language therapists. We looked for evidence of patients having access to these core specialists in the planning and delivery of their care.

There are established good practice standards for rehabilitation services e.g. Royal College of Psychiatrists.8 In common terms these standards are called the ‘AIMS Rehab Standards’ and offer a recognised, rigorous and supportive quality assurance, and accreditation process for mental health services. Although we did not set out with the expectation that all services would have obtained this accreditation status we believe that the Royal College of Psychiatrists process describes a useful set of standards/guidelines for services to aim for in the delivery of high quality care and treatment to people in rehabilitation services. There is only one service currently accredited in Scotland which is in Greater and Clyde NHS.

Rehabilitation services are where we expect to see person-centred care at its best, reflecting the following features:

• Rehabilitation care plans should be personalised with clear evidence of the involvement of individuals in their creation and delivery. • Staff will work with and get to know a much smaller number of patients and should be supported to be able to work optimally with each individual e.g. ensuring that they are given enough time to fully enact the elements of each patient’s care plan and have access to ongoing training and continuing professional development of relevance to this specialist area of work. For example, education for staff on current methods of drug testing. • The inpatient environment in which rehabilitation centred care and treatment is delivered should be fit for purpose encompassing easy access to the multi- disciplinary input required for optimum recovery. The environment should respect the dignity of individuals and reasonably conform to the same safety requirements as other wards. People whose length of stay can be up to many months will be disproportionately affected by the negative impact of a poor environment where this exists. • Being an inpatient for long periods can leave people vulnerable to being disconnected from the routine healthcare delivery that they might receive at home. It is important that people who spend long periods of time in inpatient rehabilitation services do not miss out on important physical health reviews, and are able to access national

8 https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/quality- networks/rehabilitation-wards-aims-rehab/aims-standards-for-inpatient-mental-health-rehabilitation- services-third-edition.pdf?sfvrsn=a55d0883_2

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screening programmes. Their healthcare should include lifestyle and wellbeing advice both opportunistically and as a core element of their care plan. • We expect to find that most people treated in inpatient rehabilitation services would be on medication for the treatment of mental illness such as schizophrenia, bipolar disorder or severe depression. Some people might also receive medications for additional mental health conditions such as anxiety or obsessive compulsive disorder, as well as co-morbid physical illnesses. We were interested in seeing the range of treatments inpatients were being given and in ensuring that treatments were prescribed safely with physical health monitoring in place where this was needed. We also looked at what medications were being given to people who were detained under the Mental Health Act and we checked if this was covered by the appropriate permissions and documentation. • We expect to find evidence of independent advocacy services involved with patients to assist in the promotion of their human rights. All patients have the right to access advocacy. We expect specialist inpatient rehabilitation services to have individualised activities to promote recovery demonstrated by activity planners/timetables. We also expect to see family and carers fully involved in the rehabilitation process where the patient desires such involvement. How we carried out visits We wrote to every NHS Board chief executive informing them of our planned visits to rehabilitation wards across Scotland. We asked them to confirm the location and current number of rehabilitation beds in their area. We informed them we wanted to hear the views and experiences of patients and carers about the care and treatment they were experiencing. We then wrote to these wards and arranged the visits.

We sent information to the ward managers so they could inform patients and relatives about our visit, and asked them to keep a note of anyone who wanted to meet with us. This information included posters, and leaflets for carers so they could think about what they wanted to tell us. Carer questionnaires were also left on the ward and these were completed and returned at the time of the visit or completed via a telephone call with a Commission visitor. We used a data collection templates for staff and for individual patients to capture the information contained in this report. We also looked at clinical notes and drug prescription/recording sheets. General findings – how many people etc Since 2011 we found that the number of rehabilitation beds had reduced by approximately one third. Of the 130 patients visited, just under 100 were subject to compulsory treatment. The majority of the patient population were adults aged between 25-64 years.

Age Numbers 16-24 7 25-44 48 45-64 66 65-84 7 85+ 2 130

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Patients were aware of their rights and knew how to exercise them by contacting advocacy services or their solicitor. Although there was considerable variation on the length of stay, we were disappointed that over a third of patients had been recorded as delayed discharges. This is an unacceptably high number.

We also found considerable variations in the length of stay for patients in rehabilitation services.

Length of Stay 0-3months 12% 3-6months 9% 6-12months 22% 1-2years 20% 2+ years 37%

Key findings • Services who were using core elements of the AIMS Standards for Inpatient MH Rehabilitation Services found them extremely helpful. • Patients care and treatment in rehabilitation services is set at the individual’s ability to progress to the next stage in recovery. For some this could be several months however, others may require much longer timescales. • Joint working between hospital and community services is of critical importance to the success of discharge planning. • Discharge planning works best when all disciplines are actively engaged in delivering the personalised care plan. • Recurring elements which delay discharges appear to be lack of community resources such as appropriate accommodation and/or care packages. • As people spend long periods of time in rehabilitation wards compared to acute inpatient wards, the importance of experiencing good relationships with staff in a supportive culture and atmosphere is magnified for everyone. • We found a lack of updated care plans following on from admission to the rehabilitation service, and rehabilitation goals lacking definition and detail. Recommendation one • NHS Boards should consider seeking accreditation under the AIMS standards for in- patient mental health rehabilitation services, or benchmark their service against these standards, with particular attention to factors such as: a) Delivery of physical healthcare b) Participation in purposeful and meaningful therapies and activities which reflect the preferences of patients c) Evaluation of outcomes using structured measurement tools.

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Staff and team resource What we expect to find • The AIMS standards set out what the staffing levels and skill mix should be for a defined number of beds in a unit. We expected that each service we visited would have daily access to a range of professional input including a consultant psychiatrist in rehabilitation, as well as medical, nursing, occupational therapy, and psychology staff. We also thought that there should be involvement from other allied health professionals such as pharmacy, dietetics, and physiotherapy. • We wanted to find out if there was specific training and supervision for staff working in rehabilitation, as we anticipated that staff should have the basic principles of rehabilitation and recovery-orientated practice which is r