Salford Older Adults Consultation Doc

Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 BOLTON SALFORD& TRAFFORD MENTAL HEALTH NHS TRUSTSalford Mental Health and Social Care Directorate – Older Peoples ServicesConsultation on Proposals for the Re-configuration of In-patient bedsIntroductionThis paper outlines proposals for change within Older People’s Mental Health In-patient Services in Salford, taking consideration of the following: - Outcome of the recent whole systems review  Key targets for Older People’s Services including NSF and Health and Community Care legislation  Creating more appropriate environments that will enhance and improve the quality of stay for patients in line with Safety, Privacy and Dignity requirements  Analysis of occupancy and activity levels  Current financial and contract position within Older People ServiceThe whole systems review recommended a wide range of service changes and improvements that span health and social care in-patient, residential and community based day services and multi-agency team working. The proposals in this consultation paper are concerned with the in-patient services and can be considered as the first stage of modernisation and improvement. These changes are of prime concern to the organisation and delivery of Bolton, Salford and Trafford Mental Health NHS Trust in- patient services. The proposed changes will create a more efficient and effective use of the beds without impacting on the community services. Further stages of modernisation in keeping with the whole systems review and the need to develop community based services are being planned in conjunction with Salford Social Services and these will be subject to a second stage of consultation later in 2006. ContextOver the last year attention has been given to a whole system review of services for older people through the commissioning of an independent report known as the “Lake and Lacey Review”. It is now timely to consider the service configuration and delivery of clinical services to this client group in light of the review and recommendations. The proposals in this paper build on the review outcomes and offers a plan that ensures the modernisation and development of in-patient services in line with a vision that sees the emergence of centres of excellence, addresses medical employment requirements, enables a focus of expertise, ensures fit for purpose accommodation and better meets the needs of service users and commissioners.1 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 The plans for redesign are aimed at improving the effectiveness and standards of mental health services for Older People in Salford through the delivery of a number of key targets and the continued implementation of the recommendations from the Lake and Lacey review. This work would provide the opportunity to realise a number of benefits including: Providing an opportunity to further develop specialist expertise within identified centres of excellence to manage the complex needs of patient groups, within a multi-professional, integrated framework Facilitating opportunities to modernise service models and approaches to care through improved privacy and dignity standards, and providing better support for staff by reducing isolation Providing the framework through which the service takes responsibility for continuously improving governance arrangements Providing more appropriate and ‘fit for purpose’ accommodation to meet the needs of patient groups Maintaining contract activity levels within the service thereby reducing the risk of loss of incomeThrough these service changes the Trust intends to develop centres of excellence for the provision of in-patient services to older adults. The Woodlands site will focus on people with organic illnesses whilst the Meadowbrook site will provide for people with functional illnesses. The Trust will invest capital into these sites to improve the current accommodation and ensure that privacy and dignity, space utilisation and high quality clinical environment requirements are in place to improve the patient experience during their stay as an in-patient.The focus on centres of excellence for organic and functional illnesses will be further enhanced by the appointment of Professor of Nursing for Older Adults in conjunction with Manchester University. This post will work towards improving practice-based research, supporting memory clinics and innovation in service delivery. A specific focus of the post will be to support and develop services for pre-senile dementia.Current ProvisionThe re-configuration proposals within this document need to be considered within a clear context of current provision. Up until the end of July 2005 the beds in the service were provided from a total of five separate areas of accommodation giving 108 beds. In addition the Directorate is responsible for providing support services and accommodation for a further 10 beds in the supported network. This is shown in Table 1 below.2 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 43 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 TABLE 1 (Bed configuration as at July 2005)Ward / Area No of Gender Function Beds Claremont Ward 20 Male / Female Acute organic assessment at Meadowbrook Ellesmere Ward 20 Male / Female Acute functional assessment at Meadowbrook Cavendish House 22 Male / Female Medium to long term rehabilitation for severe and enduring functional mental illness Armitage Ward at 28 Male / Female Continuing organic assessment/respite Woodlands Kenyon Ward at 18 Male / Female Acute assessment and medium term Woodlands management for men who present with impulsive, volatile, unpredictable behaviour, secondary to dementia. In-patient beds 108 Queen Alexander 7 Male / Female Supported tenancies Close Stanhope Road 3 Male / Female Supported tenanciesTotal beds 118The 10 beds in the supported network are occupied on a supported long-term tenancy basis and are 100% occupied with very little movement on to other forms of accommodation from the tenants. For the purpose of analysing activity these beds have therefore been omitted from the performance data. Table 2 below shows data from the 12 months up to July 2005 (i.e. from August 2004 to July 2005).TABLE 2 (Aug 2004 – July 2005 bed usage)No of Average Average No Ave Beds Occupancy of Beds Monthly Ward / Area used Occupied Bed Nights Claremont Ward 20 73% 14 444 at Meadowbrook Ellesmere Ward 20 93% 18 565 at Meadowbrook Cavendish House 22 72% 16 481 Armitage Ward at 28 61% 17 520 Woodlands Kenyon Ward at 18 73% 13 402 Woodlands In-patient beds 108 73% 78 2412 4 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 In August 2005 the Trust took an urgent decision to relocate the service provided in Claremont Ward on a temporary basis to Armitage Ward. This move was prompted by particular difficulties in maintaining staffing levels in the short term and associated risks with maintaining high levels of quality in service provision. Therefore since August 2005 the configuration of inpatient beds has been as shown in Table 3 with a total of 88 available beds along with the 10 beds in the network. TABLE 3 (Current bed configuration as from August 2005) Ward / Area No of Gender Function Beds Ellesmere Ward 20 Male / Female Acute functional assessment at Meadowbrook Cavendish 22 Male / Female Medium to long term rehabilitation for House severe and enduring functional mental illness Armitage Ward at 28 Male / Female Acute and Continuing organic Woodlands assessment/respite Kenyon Ward at 18 Male / Female Acute assessment and medium term Woodlands management for men who present with impulsive, volatile, unpredictable behaviour, secondary to dementia. In-patient beds 88 Queen Alexander 7 Male / Female Supported tenancies Close Stanhope Road 3 Male / Female Supported tenanciesTotal beds 98In the first 6 months of operation of the temporary arrangements the performance data (Table 4 below) shows that the directorate has continued on average to use the same number of in-patient beds across the service and that the total occupied bed nights remains comparable with the previous twelve months. The average occupancy has shown a 16-percentage point increase that is in keeping with 20 fewer beds available for use whilst retaining the level of contract activity. These figures indicate a more efficient use of the in-patient beds without compromising on bed availability and over the time period demonstrating that there is still capacity to manage fluctuations in admissions on a daily basis.5 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 TABLE 4 (Aug 2005 – Dec 2005 bed usage) No of Average Average No Ave Beds Occupancy of Beds Monthly Ward / Area used Occupied Bed Nights Ellesmere Ward 20 98% 19 598 at Meadowbrook Cavendish House 22 80% 18 545 Armitage Ward at 28 83% 23 709 Woodlands Kenyon Ward at 18 90% 16 497 Woodlands In-patient beds 88 89% 76 2349 Consultation ProposalsOlder Peoples services will provide high quality, evidence based mental health services for adults over the age of 65 with functional mental illness and to adults suffering from organic illness. This will be delivered through a range of multi-disciplinary services depending upon severity of mental health need and complexity of other co - existing pathologies. The purpose of all inpatient services is to provide care and treatment to individuals who present with a severe mental health need as a predominant feature and where, to leave the individual in their current environment would present as a high level of unacceptable risk. An outline of the proposed future service provision is detailed below: -Ellesmere Ward – Meadowbrook siteThe location of this service provision will remain on the Meadowbrook site and its function will continue as a 20-bedded acute assessment unit for males and females with functional illnesses. The location of the beds will move to Claremont ward.Core BusinessIt is envisaged that the core business of this area will be men and women, predominantly over the age of 65 with acute functional illness. This could be a first onset or a relapse of a previously diagnosed condition. Functional illnesses assessed within this area will include depression, anxiety, bipolar disorder and psychosis. These individuals are acutely unwell and require multi- professional assessment, treatment and active risk management. Older people often present with multiple pathologies, however where the physical health care needs is the predominant feature and there is medical6 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 instability admission will not be considered until the physical condition has stabilised. Model of CareThe multidisciplinary approach to care will continue to be developed and enhanced promoting the Recovery Model including Psychosocial Interventions and Cognitive Behavioural Techniques and will follow the NICE guidelines for these known conditions.A multi professional team consisting of medics, nurses, occupational therapists and psychology will deliver this model of care. New roles to be developed to incorporate STR Workers and areas of skill, expertise and leadership will be developed in PSI & CBT. Transfer of Claremont to Armitage – Woodlands siteIn August 2005 Claremont Ward transferred to Armitage Ward on a temporary basis. It is proposed that the amalgamation of the two services becomes a permanent arrangement. Armitage will therefore continue to function as an acute organic assessment ward.Rationale: Patient group is broadly similar in diagnoses and support requirements.  Consistent under-performance on contract activity in both Claremont Ward and Armitage Ward  Claremont is an inappropriate environment for Older People with organic mental health needs  Provides an opportunity to review and develop expert medical input to the Woodlands site  Provides an opportunity to review skill mix and develop specialist expertise to manage the complex needs of this patient group on one siteCore BusinessThe core business of this area will be men and women over the age of 65 who are acutely organically unwell. Additionally the ward will also accept people under the age of 65 with an early onset dementia whose condition is presenting as acute. Respite care is also available for individuals whose needs cannot be met by other services.The presentation of individuals requiring admission will be of such a degree of severity that the individuals’ care cannot be provided by any other provision and to leave them in their current environment would present as a high level of risk. Examples of this may include disorientation, agitation and restlessness,7 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 being unreceptive to reassurance and or distraction, high levels of distress and deterioration in activities of daily living. Older people often present with multiple pathologies, however where the physical health care needs is the predominant feature and there is medical instability admission will not be considered until the physical condition has stabilized. However, palliative care may be provided for those individuals where this is deemed to be the most appropriate environment and their care needs can be met by the multi professional team.Model of CareThe model of care will continue to develop to one of promoting and delivering excellence in dementia care and assessment whilst promoting a person centered approach.A multi professional team consisting of medics, nurses, occupational therapy, physio and psychology will work closely with the individual and their carers to undertake an in-depth person centered assessment and develop appropriate evidence based plans of care as a result of this. The focus of the assessment will be one of promotion of stability and enablement thereby maximizing an individual’s independence and remaining skills.Additionally levels of expertise will be developed in end of life care and end of life care pathways will be introduced.Kenyon Ward – Woodlands siteThe location of this service provision will remain the same and its function will continue as an 18- bedded acute assessment and medium term management ward for men who have organic impairment and challenging behaviour. Respite care is also available for individuals whose needs cannot be met by other services.Core BusinessThe admission criteria for this area will be men over the age of 65 who have organic impairment and are presenting with challenging behaviour. The presentation of this challenging behaviour may include unpredictability, poor impulse control, sexual dis-inhibition, un-provoked aggression. Additionally, men under the age of 65 with early onset dementia who present with the above behaviour will also meet the admission criteria.However where the physical health care needs are the predominant feature and there is medical instability admission will not be considered until the physical condition has stabilized. 8 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 Model of CareA model of care will be provided that continues to develop and promote excellence in managing challenging behaviour within dementia care, utilising a person centred approach.A multi-professional team consisting of traditional and new roles will be developed to support the assessment, management and enablement of an individual’s independence.To support the developments and promote leadership and excellence in care throughout the in-patient dementia services, additional new roles are being explored including a palliative care pathway facilitator, advanced practitioner, consultant nurse/therapist, and STAR workers.Cavendish House Transfers to Meadowbrook SiteCavendish House is an old 4-storey building which does not provide sufficient living space for individuals requiring a longer in-patient stay and some areas of the building are ‘out of use’ due to access restrictions and fire regulations. The building is not fit for purpose structurally and does not meet functional suitability. The permanent transfer of the Claremont Ward function to Armitage Ward would free up existing ward accommodation to enable the service to transfer the Cavendish House function to Meadowbrook site occupying the current Ellesmere ward. The proposal to move this facility to the Meadowbrook site will concentrate the specialty of managing functional illness within one environment. Rationale: Cavendish House is an isolated, satellite unit with no provision for immediate staffing support in an emergency  Creates an opportunity to strengthen SHO input for this patient group  Consistent previous under performance on contract activity with occupancy levels running at approx 65%  A recent review of patient profiles in Cavendish House suggests approx 4 - 6 individuals would be better placed in supported tenancy arrangements  Provides an opportunity to work with relevant partners to increase the provision of supported accommodation in the city  Provides an opportunity to review the philosophy and model of care for this patient group  Provides an opportunity to review the staffing and skill mix required to support a revised model of care  Consolidates the skills and expertise within the workforce, in managing patients with functional illnesses, on the Meadowbrook site9 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4  Will facilitate and improve links between under 65 and over 65 functional services e.g. increases shared use of facilities, levels of expertise.Core BusinessOlder people with severe and enduring functional illness who require medium to longer term rehabilitation. This group of people may have a history of being treatment resistive, higher relapse rate and as a result of the long term impact of their illness may display challenging behaviour. Therefore complexity of the health and social care needs of this client group means that community care is not an appropriate option at this time.However where the physical health care needs are the predominant feature and there is medical instability admission will not be considered until the physical condition has stabilisedModel of CareThe model of care will focus upon a recovery / re-enablement model. It is envisaged that this model will promote independence and social inclusion for each individual. The aim will be for all individuals to increase their independence to enable them to move on to a less dependent living environment / home. The increased network provision of QAC and Stanhope will support this transitional approach. A multi professional team consisting of medics, nurses, occupational therapists and psychology will deliver this model of care. New roles to be developed to incorporate STR Workers and areas of skill, expertise and leadership will be developed in PSI & CBT. Increase the Availability of Supported TenanciesTo support the review and reduction of inpatient beds in Cavendish the service would want to develop and increase the supported accommodation available at Queen Alexander Close by an additional 4 beds.Queen Alexandra Close and Stanhope are supported tenancy properties for individuals with a history of enduring functional illness who have stabilised to a degree where by they no longer require in patient services, however without close and regular support, interventions and monitoring by skilled mental health staff these individuals would quickly relapse. The planned increased provision in this area will further support the hub and spoke model of care with this client group (the newly provided Cavendish being the hub) Rationale:10 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 Will support the philosophy of ‘hub and spoke’ model of care for older people with severe and enduring functional mental illness with the new ward at Meadowbrook acting as the ‘hub’  Will develop existing provision on the QAC site  Opportunity to create 4 additional supported places in the Community, with the potential to expand the scheme further  Housing agree, in principle, to support this development and have a suitable property available  A review of staffing and skill mix will allow service provision to be extended within current resources  Supports social inclusion agenda  Would enable staff to rotate through the ‘hub’ to develop skills and expertise, following patients into the ‘spoke’ (QAC)Core BusinessOlder people with enduring functional mental illness who no longer require an in- patient setting, but whose illness prevents them from successfully living independently.These individuals mental health condition, without close monitoring, support and interventions by mental health staff would quickly deteriorate and in patient admission would be required. All individuals living in the network will be tenants of the property and will also be registered with a local GP for their physical health care requirements. Model Of CareThe model of care will echo that of Cavendish / Claremont in one of a recovery / re-enablement model. As previously mentioned Cavendish / Claremont would act as the hub with the network becoming the spoke. This would enable individuals to move from Cavendish to a less structured setting whilst still having their mental health needs closely monitored.Likewise staff would also be able to rotate through the hub to develop their skills and expertise and follow individuals into the spoke. This also enables a more consistent level of care to a client group very sensitive to change and will allow staff to develop greater knowledge of the clients and heightened awareness of triggers and signs of relapse. The extra provision of tenancies at the Network will be supported within existing staffing resources and allow this area to further develop. Table 5 below shows the proposed configuration of beds following the changes. It can be seen that the only changes to the post August 2005 configuration is a reduction of three beds associated with the Cavendish11 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 House service. This is manageable based on the last six months occupancy levels without impacting on requirements and resources in community based services.TABLE 5 (proposed bed configuration) Ward / Area No of Gender Function Beds Ellesmere Ward 20 Male / Female Acute functional assessment at Meadowbrook New Cavendish 15 Male / Female Medium to long term rehabilitation for ward at severe and enduring functional mental Meadowbrook illness Armitage Ward at 28 Male / Female Acute and Continuing organic Woodlands assessment/respite Kenyon Ward at 18 Male / Female Acute assessment and medium term Woodlands management for men who present with impulsive, volatile, unpredictable behaviour, secondary to dementia. In-patient beds 81 Queen Alexander 11 Male / Female Supported tenancies Close Stanhope Road 3 Male / Female Supported tenanciesTotal beds 95ImplicationsThe above proposed in-patient bed changes can be achieved without the need to alter the current admission and discharge criteria. It is expected that the current “throughput” of patients will remain at the existing levels. These changes amount to a more efficient use of the in-patient resources without impacting on the resources in community based services. The whole system review did recommend further reorganisation of services across day provision and multi-agency community teams. This will be subject to ongoing multi-agency work to explore how further efficiencies and developments can occur. To underpin the proposed next stage of service redesign and models of care a range of activity is currently being undertaken. This includes the establishment of multi-agency working groups on each development area to identify:  Patient profiling in all clinical areas to support core business identification  Review of dependency levels and staffing ratio  Review of current literature and evidence on service models and interventions, national guidance, local directives.12 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4  Local and regional networking to identify existing examples of best practice  Achieving understanding and consensus on core business definitions across agencies We recognise that further changes will require more medium and longer term planning in partnership with key stakeholders and other service providers in order to fully meet the vision set out by Lake and Lacey, however, this paper identifies the changes we feel we need to implement at the earliest opportunity. The changes identified in this paper will result in the release of resources to contribute to the next stage of reconfiguration. It is anticipated that approximately £140,000 will be released for reinvestment. The priority areas being considered are:- Development of specialist Community mental Health Teams- Review of intermediate care and day services for older people with dementia- Further development of Liaison Service with Salford Royal HospitalThe Trust acknowledges that there may be some potential risks associated with a higher occupancy level and is therefore willing to discuss with social services and the Primary Care Trust how best to support the commissioners in managing these risks. In addition the Trust will pump prime ‘at risk’ grown in community intermediate support from April 2006 up to £140k (non-recurrently), pending partnership agreement on community service development and investment plans as part of the second stage of reconfiguration. It is likely that further resources will be available as part of the second stage of reconfiguration. These issues will be discussed with local partners and investment planned on a multi-agency basis.The changes highlighted in this paper will require capital investment to ensure facilities meet increased occupancy. The Trust is planning to make approximately £350,000 available during 2006/07 to include the following works:Armitage Ward - Heating to corridors - Reprovision of lounge. Storage area and rehabiliation kitchenEllesmere Ward - Minor works / redecoration13 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4Claremont Ward - To bring current building to standard and ensure 'fit for purpose'Queen Alexander Close - Upgrade of No 1 and No 10Woodlands Day Hospital - Reconfigure and make secure garden areaKenyon Ward - Upgrade of facilities where appropriateConsultation ProcessConsultation on the proposals in this paper will be for a period of six weeks commencing on Monday 3 April 2006 and concluding on Friday 12 May 2006. The Trust is committed to sharing these proposals with all interested parties during that period. Copies of this document will be sent to all staff and staff side representatives, service user groups and carer forums, other statutory and independent sector providers, voluntary and support agencies, service commissioners, local authority elected members, and representative members of Parliament. The Trust will work with the Salford City Council’s Overview and Scrutiny Committee in ensuring that due process has been followed and consideration of the outcomes of the consultation have been given and where appropriate incorporated in any final arrangements.Important dates and meetings during the consultation include:BST Trust Board meeting 27th March 2006 Salford Older Peoples Partnership Board meeting 10th April 2006 Reach Beyond Carers Forum meeting 11th April 2006 Salford Mental Health Partnership Board meeting 12th April 2006 BST UACT meeting 20th April 2006 Older Persons Development Group 3rd May 2006 Salford PCT Board meeting 11th May 2006 BST PPI Forum 16th May 2006In addition the Directorate management team will organise a number of specific meetings for staff to share the content of the paper and address any questions that may arise. Members of the management team will also be available to present the paper and answer questions that arise to interested groups and organisations upon request.The process followed and responses to consultation will be presented to the Overview and Scrutiny Committee meeting on 18th May 2006.14 Community, Health and Social Care Scrutiny20 April 2006Agenda item: 4 Responses to any aspect of these proposals are welcome and should be sent to:David Entwistle Director of Mental Health and Social Care Services of Salford Meadowbrook Unit Stott Lane Salford M6 8HG Email: [email protected] Telephone: 0161 772 3771 Responses to arrive no later than 1700 hours on Friday 12 May 2006.15

Salford Older Adults Consultation Doc

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