Coral is the intensive ward for female patients in The National High Secure Healthcare Service for Women that provides care for six of the most complex and challenging patients in the service, who suffer from a mental illness, personality disorder and learning disabilities.
The criteria for admission includes unmanageable behaviour on current ward or area, extreme self-injury to a life-threatening or life altering degree, assaultive behaviour and increased use of seclusion, mechanical restraint and/or segregation. The majority of the patients have illnesses that are treatment resistant entwined with an extensive history of traumatic experiences such as childhood abuse.
The Coral team was established on the 1st May 2017, when Emerald A and B separated into two wards as a pilot for six months due to the nature of the different patients on either side of the ward. One side catered for intensive care patients and the other side catered for patients with a diagnosis of learning disability or were deemed to have vulnerability needs. This meant that each ward had its own management structure including ward manager, MDT and staff team, thus providing a focused approach to the patient groups and provided stability for the ward teams.
Coral has a high level for incidents whether that be self-injury or aggression, thus all of the patients are managed by the use of segregation, seclusion and/or mechanical restraint. Levels of within eyesight observations are high. Patients spent significant amounts of time isolated in their rooms and staff sat outside observing them. This resulted in staff morale and patient motivation decreasing.
Recognising this, targets were set for ward performance to improve by increasing annual appraisals and supervision rates, reducing staff sickness and patient outcomes improving, focusing on activities, and reducing restrictive practices such mechanical restraint and long term segregation and incident rates, in turn having a positive impact on patient and staff experience. These were discussed and agreed with the Coral team, patients and Senior Management Team.
Reducing staff sickness would have a financial impact as if this was reduced it would cut the amount of money spent on bank and staff required. Increasing the amount of support staff get through receiving clinical/managerial supervision and annual appraisals will increase staff morale as they would feel invested in, valued and supported. Increasing the amount of activities would reduce incidents due to patients being occupied, thus reducing the need for restrictive interventions.
Since May 2017, Coral has gone from strength to strength. It now has a permanent ward manager and team leaders that are invested in it and lead from the front. The ward is organised, well-led with an established and experienced team. A no blame culture and devolved leadership is the norm. The staff have therapeutic rapport with patients, providing an environment where patients feel safe. The MDT is effective but also not afraid to challenge each other.
Decisions are made collaboratively with the patients. The team have a positive attitude and are motivated to reduce restrictive practices with patients spending less time in mechanical restraint and more time out of segregation. Meaningful activity has increased; patient social skills have improved, resulting in a reduction in incidents of life threatening self-injury and aggression.
Staff sickness has reduced, the uptake of supervision has increased and the number of staff having annual appraisal reviews has increased. Initial challenges were staff not feeling confident to nurse high risk patients out of segregation. Getting the whole MDT team on board with the re-integration planner was difficult as it was a total change in how we managed patients. Despite this the planner was embraced by all.
The work that Coral has done is scalable and replicable on wards where there are high rates of restrictive practices; segregation and mechanical restraint. Having the right culture which has been created by leaders that are authentic and motivated to improve the experience of patients and staff and an MDT that is open to positive risk taking and promoting a no blame ethos, along with staff that are encouraged to be devolved leaders and feel safe to do this by being invested, creates a highly motivated skilled team that are positive about patient care and experience.
The Coral re-integration planner is a tool that ensures that staff and patients are organised each day and know what they are supposed to be doing from one day to the next. It ensures that all patients are receiving integration time in communal areas, meals and promotes social and interpersonal skills.
Coral’s re-integration planner gained praise in Rampton Hospital’s Safe and Ethical Restrictive Interventions Governance Group for our radical, positive plan for reducing segregation on an intensive care ward with the most complex, challenging patients within women’s service. Good practice was also discussed on the Trust’s Twitter site and in Rampton Newsletter.
Coral ward has seen many changes and benefits due to the team’s dedication to improving the ward thus improving safety for the patients and staff team. The overall staff sickness levels have dropped and there is now more time to provide support to staff that are working in a very intense environment, thus improving the financial value as extra staff are not having to be recruited to cover staff sickness (see supporting evidence).
The ward manager has an open door policy and drop-in sessions for staff. There is dedicated group supervision time and also space to discuss patient case formulations to increase staff knowledge and understanding of each patient. Staff meetings happen monthly and ward community meetings are carried out fortnightly.
A more structured approach to ensuring the patients in long term segregation have time out of their rooms was put in place on the 23rd January this year with the implementation of the Coral Re-integration Planner (see supporting evidence), resulting in patients spending more time out of their rooms and two patients segregations being discontinued altogether.
Staff engaged through monthly staff meetings, away days, and are afforded weekly group supervision time, individual clinical supervision each month, managerial supervision provided by Ward Manager/ Team Leader each month. The Ward Manager has an open door policy staff can see her at any time, also has a drop in session for staff every Wednesday morning.
Staff of any grade who are on the patients team attend MDT meetings improving communication and understanding of the patient but also to empower them and involve them in decision making. Staff are to complete feedback forms on what they believe we are good at and what standards we are working hard to improve.
Patients engage through fortnightly community meetings and weekly planned named nurse sessions. Ad hoc sessions will be provided by staff. Ward manager has a session each week on a Thursday morning. Patients are also asked to complete feedback forms. Any ideas regarding the ward are discussed through the above meetings. It’s very important that staff and patients were on board with the change for it to be successful; it was a change in culture for the patients to be out of their rooms and socialising in communal areas.