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Award-winning rehabilitation team enables mental health service users to live independently at home

How RCNi Nurse Awards Team of the Year provides rehabilitation for people with mental illness, enabling them to live in their own homes

How RCNi Nurse Awards Team of the Year provides rehabilitation for people with mental illness, enabling them to live in their own homes

  • Bespoke packages of care enable people to live close to family and friends
  • Service has reduced emergency department attendance and hospital admissions
  • Innovative approach is credited with improving lives of disenfranchised people
Debbie Creaser with members of her award-winning community enhanced recovery team, RCNi Nurse Awards Team of the Year, who provide rehabilitation for people with mental illness, enabling them to live in their own homes.
Debbie Creaser: 'Working in inpatient rehabilitation I knew there was a lot of frustration
around unnecessary restrictions and too much risk aversion' Picture: John Houlihan 

Sandra Perry’s depression and mood swings have meant frequent and long admissions to care since 1992. These included a three-year inpatient stay that ended four years ago, when she came under the care of the community enhanced recovery team (CERT) at Sheffield Health and Social Care NHS Foundation Trust.

‘Some people call me crazy but thanks to CERT I am well into recovery,’ says Ms Perry. ‘They are wonderful. There is nothing they won’t do. They do my dishes and tidy up when I am feeling overwhelmed and depressed. They take me out when they don’t have to.

What the judges say

Judge Caroline Shuldham, chair of the RCNi editorial advisory board, says: ‘Debbie and her team have a wide view of health that encompasses key factors such as housing, education and employment.

‘They took on the challenge of developing a multiprofessional team, designing an innovative approach and establishing partnerships with other organisations.

‘In doing this they provided a high-quality service to a disenfranchised group of patients, improving their lives considerably. Impressive teamwork has yielded great results.’

‘They respect me and don’t judge me at all, even when my house is untidy. But if it weren’t for them it would be chaos.’

‘They treat me special’

‘They come to visit at least twice a day through hell and high water. You can set your clock by them. I don’t know why but they treat me special.’

The CERT team provides intensive mental health rehabilitation and recovery by delivering bespoke packages of care to people in their homes.

The model was born almost five years ago when nurse Debbie Creaser was given the job of finding out how many Sheffield patients were at out-of-city inpatient hospitals.

Patients with little hope

She found scores of patients throughout England with little hope of leaving institutional care.

‘I would talk with consultant Mike Hunter about what we could do for these patients while grabbing a coffee, and before we knew it we were presenting our unusual idea to the board,’ she says.

They negotiated with commissioners to manage the out-of-city budget, using it to bring patients home and support them in their community.

‘I had a lot of hope that people could live independently – they certainly did not need inpatient care permanently’

Debbie Creaser

‘It has grown so much,’ says Ms Creaser. ‘Our initial plan was to work with 12 service users, employing four nurses as care coordinators and 17 recovery workers from a range of different backgrounds. And they have done the job brilliantly.’

Shortlisted applicants for the recovery worker positions went through two days of values-based recruitment, working through four exercises to assess their match against the job specification.

‘At first we weren’t working with that many service users, but we were working with them 24 hours a day,’ says Ms Creaser. ‘We realised quickly that it was unnecessary, and people found our approach more restrictive than being in hospital.’

Patient Sandra Perry (left) with recovery worker Sharni Stevenson and Debbie Creaser (right). Their RCNi Nurse Awards Team of the Year provides rehabilitation for people with mental illness, enabling them to live in their own homes.
Patient Sandra Perry (left) with recovery worker Sharni Stevenson and
Debbie Creaser (far right) Picture: John Houlihan

Some people had been inpatients for more than ten years. Moving them into the community had ‘a massive risk attached to it’, concedes Ms Creaser.

‘It might not work and something catastrophic might happen, but working in inpatient rehabilitation I knew there was a lot of frustration around unnecessary restrictions and too much risk aversion,’ she says.

‘I had a lot of hope that people could live independently – they certainly did not need inpatient care permanently. People had more skills than they were given credit for.’

‘Inpatient stays de-skill people’

Ms Creaser gives an example of staff putting up barriers to prevent a woman having home visits.

‘A few months previously she had taken unauthorised leave and decided to go on a trip, using different forms of public transport, asking directions when lost and showing resilience. To the care team, she absconded. To me, she showed key skills that could help her live independently. Inpatient stays de-skill people.’

Before an inpatient is brought back to Sheffield, a member of CERT builds a relationship with them for weeks or months.

‘You have to know the person,’ says Ms Creaser. ‘People will be inviting us into their home so we need to be familiar. We need to know their skills and difficulties. It can be such a difficult transition from so much restriction to having independence.’

Restriction can make people iller

And often the restriction is making people iller. Ms Creaser recalls a service user in an out-of-city inpatient rehab ward with increasingly frequent and long admissions to a psychiatric intensive care unit.

‘The woman would become unwell extremely quickly and was deemed dangerous, so her care plan said to send her straight to the psychiatric intensive care unit if she was unwell, under police escort,’ says Ms Creaser. ‘Eventually the care team felt that she could no longer be supported in the unit.

‘We need to know if they would cope independently and find out why this is not happening’

Debbie Creaser

‘Over six months to a year care coordinators visited before she was discharged and for nine months there have been no admissions. She tells us when something is not quite right and, if she becomes unwell, she just needs a couple of days admission and then goes home.

Approach may not work for everyone

‘People were putting lots of restrictions on her. It was an adversarial approach. I was not 100% sure she would manage in her own home, but there has been such a difference, and she would have faced a long time in inpatient care.’

The approach may not work for everyone, she says, but healthcare staff owe it to people to try: ‘We need to know if they would cope independently and find out why this is not happening.’

Members of the community enhanced recovery team at Sheffield Health and Social Care NHS Foundation Trust. The RCNi Nurse Awards Team of the Year provides rehabilitation for people with mental illness, enabling them to live in their own homes.
Members of the community enhanced recovery team at Sheffield Health
and Social Care NHS Foundation Trust Picture: John Houlihan 

Taking on the level of risk can be a ‘big ask’ of staff, says Ms Creaser.

‘For one of our service users, the level of risk of self-harm was so extreme we had to carry ligature knives and she had to be resuscitated. But we balance that with, if she was to die, she will have had the best quality of life.’

From straitjacket to home

Before coming under CERT’s care the woman had had an extremely restrictive 24-hour package of care with no personal belongings.

Ms Creaser recalls: ‘In hospital she had to be in a ward straitjacket. She couldn’t do anything for herself, even shower. Absolutely everything was observed.

‘It frustrated her and she behaved badly to battle with staff.

‘She was released to us and we quickly had to reduce support down to four hours as that was the best way to work with her. She just could not cope with all the attention and observation.’

CERT has brought more than 50 patients back to Sheffield, with most now living independently in their own homes. Bed night use has been reduced 99% for CERT patients, and the number of service users attending emergency departments or being admitted to hospital has also reduced.

These savings fund CERT and also deliver an additional saving of £500,000 for the trust.

Input into the care plans

The service’s partnership with South Yorkshire Housing Association has been central to its success.

The team knew that service users would need more than just mental health support to transition to independent living successfully and the housing association gives them tenancies that they retain even after discharge.

The team’s non-hierarchical structure is also crucial. It uses a case formulation approach so the whole team shares their theoretical and experiential knowledge of the issues presented by service users. Everyone has input into the care plans and the nursing leadership in the team makes sure every member’s views are respected and valued.

This ‘whole team’ approach and its unique partnerships saw CERT named Team of the Year in the 2019 RCNi Nurse Awards.

Singing and dancing

Ms Perry has been deeply affected by the death of her son, and mentions him frequently, but the CERT team has brought joy back into her life.

She looks forward to their visits. ‘I’m the hostess with the mostest,’ she says.

And she has started swimming. ‘CERT is a holistic model,’ she enthuses. ‘I did my lifesaver’s in the past and I was an athlete in the South Yorkshire team for sprinting and long jump.’

But most of all she loves the music group. ‘Before I go I feel anxious,’ she says. ‘But when I get there we all get together. Andrew [recovery worker Andy West] plays drums. He’s fantastic and he keeps us in order. I’m on tambourine, singing and dancing. And it all comes together in harmony and I feel much better. It’s amazing.’ And what’s her favourite song? She sings it with gusto: Beyonce’s Independent Woman.

‘They build their lives and reflect that back to us’

Andy West has been working as a recovery worker for the community enhanced recovery team (CERT) since 2015. He has a master’s degree in psychology and wanted to work in mental health.

‘I love the values-based recruiting and it was an excellent way of seeing who was right for the role,’ he says.

‘We help them learn to manage’

‘The role can be challenging. It is hard for people to settle into the community when they have been in hospital for a long time. It is so different.

‘Some people you meet have been in hospital for more than ten years and they are really anxious. Quite often they lapse, so how we manage that as a team is important. People can be anxious and shouting when we visit them and we have to help them learn to manage that.’

‘Over time their anxiety lessens’

But it is also rewarding, he says, as you build a therapeutic relationship. ‘You really get to know service users and over time their anxiety lessens,’ says Mr West.

‘They go to meetings and go to groups, build their lives and reflect that back to us.

‘And you have helped them live in their own home. That is just massive for people but often we take it for granted. We get to be a part of that.’

It is CERT’s team approach that makes it such a success, he says. ‘The flattened hierarchy means people feel valued and the challenges that we face are recognised and addressed through protected and regular time for reflection.’


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