Valuing People - Implementing a Programme to Reduce Restrictive Practices

Liz Williams, Clinical Services DirectorCambian Group

Overview

• Why did this programme of work come about?

• The programme – as it emerged• Themes• Impact and outcomes so far• Challenges• The journey…what has worked and what

hasn’t?

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Drivers: Why was this programme of work started?

• CQC inspection November ‘13, following concerns raised re: two patient reviews

• Commissioners raised concerns

• Staff concerns

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• “On Oak and Beech Court we found that people’s care was not consistently effective, caring and responsive to their needs. The design and layout of these units did not ensure people’s rights to privacy and safety. People on Oak Court told us that they did not always “Feel safe” on the unit because of the behaviour of others”. We found that people who used the service were not being protected against the risk of unlawful or excessive control or restraint. We found that there was not qualified, skilled and experienced staff to meet people’s needs. Staff were not being supported to deliver care and treatment safely and to an appropriate standard.”

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The whole picture

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Management response

• Restructure – to direct resources to support the service to address the issues

• Action plan to CQC; action log devised –to monitor the actions and form cross cutting programmes

• Weekly call to oversee log (with MD) – with key personnel

• Quality team brought in to support/ Education service consulted

• Multi disciplinary review group including staff at all levels and patients convened to share ideas

• Positive behaviour Support Group convened to look at moving to positive behaviour support model and reducing restrictive practice

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The Reducing Restrictive Practice Programme

• Overall aim: to re-balance to the use of proactive and reactive strategies and reduce the use of restrictive practice in a way that is planned, sustainable, measurable and evidenced

• Programme devised from elements of the CQC action plan, BILD Framework and Positive and Safe

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Frameworks…

• BILD Framework for reducing restrictive practice in the CQC context

• The two year programme: ‘Positive and Proactive Care: reducing the need for restrictive interventions’ guidance launched

• DH summary of action – used as audit tool

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Elements of the programme

•Tailored psychology led intervention•Staff briefings: awareness raising

including legal responsibilities and invitation to explore the grey areas and take ownership of their practice as a team

•Staff training/ induction in care planning, risk assessment and positive risk taking

•Systems in place to gather information, monitor and challenge practices put in place

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Psychology led intervention

• Intensive support to deliver cultural change in restrictive practices

• 30 support workers on Oak Court and Beech Court given intense, hand-on support in the use of care plans and positive behavioural management plans

• Understanding measured before and after support• Rolled out across all units• Linked to training from the lead in ‘active care’

including face to face training and ‘in situ’ training in risk assessment and management

• Input into induction training to lay the foundations for new staff

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Staff briefings

• Over five weeks, two mornings a week • Safe space – no direct heads of service

present• Define restrictive practice • Open the conversations, using examples• Consider the ethical use of restrictive

practices – in detail• Develop themes• Listen to ideas

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Assessment against DH guidance

• CQC action plan included action to ensure data was collected to monitor use of all interventions – high level MVA, prone and supine

• Assessed actions against the DH summary guidance: • Improving care• Leadership, assurance and accountability• Transparency• Monitoring and oversight

• Added trigger points for case review• Pharmacy adult convened to baseline use of

medication including PRN, IM• All led by Positive Behaviour Support Group and

fed into clinical governance by report on a monthly basis

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Listening to staff: staff leading changes

• Teams owning the examples and themes through briefings and discussion

• Amnesty box for e.g.’s• Regular update – themed paper• Key rings – safe and ethical use of

restrictive practice• Staff at all levels joining the positive

behaviour support group as leaders• Monthly update meetings

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Themes: as articulated by staff

• Balance of risk/ restriction is grey area• Use of the red/ green risk assessment –

systems do not support • How do we involve patients, families and

carers and advocates in this process in a meaningful way

• Consequences/ punishment/ duty of care• Units that support people with ASD are finding

this more complex• Behaviour of some patients restricting other –

balance therapeutic environment• Use of medication

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Challenges

• Data capture and quality• Cultural change – ways of working• Establishing the therapeutic relationship

between staff and patients• MDT joint working• Staffing – numbers/ experience/

qualifications!• Wider context of quality of life, move on

and discharge• Roll out across the whole of the division

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Impacts to date

• Reduction in high level MVA (to 0 in two units)

• Case reviews enabled re-balance for four people who had experienced the greatest

• Staff at all levels are challenging formulation in ward round, offering ideas e.g. waterfall

• Paper work massively improved – QA audits• Therapeutic relationships improved –

according to advocacy

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