Mental health unit rewarded for turnaround efforts

Brookside Adolescent Inpatient Unit has been busy taking its Care Quality Commission rating of inadequate to outstanding in 18 months, and the hard work has paid off, to win the Mental Health Practice award

Pete’s mum was desperate. Her transgender son was self-harming, anorexic and regularly trying to take his own life. The nearest eating disorder unit place was 400 miles away. She went from pillar to post pleading for somebody to help them. ‘Don’t tell him,’ said a mental health professional on one occasion after another emergency admission for a suicide attempt, ‘but your son is not suicidal enough'.  

Trying to remain positive was tough for Pete's mum, 'Pete kept asking “why won’t anyone help me mum?” and I would reply “don’t worry we will find someone” even though everything was crumbling.'

Finally, Pete was admitted to Brookside Adolescent Inpatient Unit in Essex. ‘It was wonderful,’ she says. ‘The staff were kind and caring. They were lifesavers – literally.’ 

Had Pete been in Brookside for treatment previously, he might've had a different experience. The inpatient unit was struggling with a 58% vacancy rate. 

Watch: RCNi Nurse Awards 2018 Mental Health Practice winner Rebekah Bewsey on her project

Containment, not therapy, ethos

‘It was not safe,’ says modern matron Rebekah Bewsey. ‘There were unknown ligature risks and high use of restraint – 459 in a 12-month period including prone positions. There were many restrictive practices, including locked doors, personal searches and blanket restrictions. The ethos was containment not therapy. Care plans were neither recovery orientated or holistic.’ 

The Care Quality Commission (CQC) inspected and rated the trust inadequate.

‘It was not completely unexpected – we were already on a journey – but I cried in the boardroom,’ says Ms Bewsey.

But with strong nurse leadership and a commitment from all to transform care for its young people, in 18 months the newly-modernised Brookside Adolescent Inpatient Unit, supported by one of the country's first 24/7 Young People's Home Treatment Team (HTT), had earned an outstanding rating. 

For this unprecedented turnaround and the quality of the care it now gives its young people, the team was this month named winner of the Mental Health Practice category of the RCNi Nurse Awards, the profession’s top accolade.

Unprecedented turnaround

‘Our new innovative model for inpatient Child and Adolescent Mental Health Services (CAMHS) care has allowed us to provide outstanding care and treatment to young people and their families in an as least a restrictive environment as possible, with recovery-focused, patient-centred care at the heart of everything we do.’

The HTT, offering Tier 4 care at home, is crucial.

‘We decided to offer an alternative to inpatient admissions,’ says interim young people’s HTT manager Emma Berry, ‘in part driven by a temporary closure of Brookside, and in part by the desire to develop a truly innovative solution for young people receiving mental healthcare.

'The HTT has prevented 244 inpatient admissions by allowing young people to be cared for at home with their families'

HTT manager Emma Berry

‘We wanted to offer 24-hour crisis provision, increasing scope for positive risk taking and treating young people in the least restrictive environment. It would create seamless transitions between inpatient and community CAMHS and promote continuity of care.’ 

It has been a ‘phenomenal’ success, say nurses. ‘We have young people who had been in hospital for more than two years, now at home with their families and back in college,’ says Ms Berry. 

'It has prevented 244 inpatient admissions by allowing young people to be cared for at home with their families, in their social circles, able to continue their hobbies and activities.' 

The HTT has enabled the service to assess young people 24/7, rather than 9am-5pm. ‘We can outreach into section 136 suites, schools, home, police stations, and meet the mental health needs of these young people in crisis who are already in distress so they are not being passed from pillar to post to ED.’

With in-reach work speeding discharge to the community, the team has reduced inpatient stays from an average of over 90 days to 30 days. The young people are supported by the team for 45 days, which is significantly less than the national benchmark of 90 days. 

Parents feel that is has bridged a gap. One parent said: ‘I can’t praise this service enough on previous discharges, without this level of support our daughter has struggled. This has given her a chance to stay safe during those early, fragile weeks and hopefully longer term.’

The team has found the approach particularly beneficial for young people who experience emotional deregulation, have a high risk of self harm, or who have personality disorder emerging.

‘They do not do well in inpatient settings and tend to escalate. Without this new service, these young people would have been admitted to inpatient units over the country.’ 

Young people and their families helped shape the new inpatient unit’s design and to support new pathways and practices, the management team invested heavily in staff. The rate of appraisals is up from 43% to 92% and a recruitment drive cut the vacancy rate to 20%. Staff have received bespoke training.

‘There was a lot of press and negativity but what the staff achieved was phenomenal,’ says modern matron Rebekah Bewsey. ‘There was a visible management presence on shift, leading by example and empowering staff. There were staff away days to give space for reflection. 

‘Previously, care planning had not involved young people, but was based on an adult plan so I led a quality improvement project to change the way they were created so they were young people-focused had pictures on. Now care plans are comprehensive, person centred, recovery orientated and relevant and there are a wide range of therapies available.’

‘There were real concerns around user involvement before, and families were not involved in care. But with our more proactive practice model and more staff, we are able involve families and build therapeutic relationships with them.’

The CQC found that staff were highly motivated, inspired to offer care and support people’s dignity. The CQC said young people were supported in expressing their views and in realising their potential and staff were involved in recruitment.

Patients and families were very positive about the service in response to the CQC stating they 'received excellent care and staff were amazing' and 90% of carers and patients would recommend the service through The NHS Friends and Family Test.

The service is much safer – restraints dropped from 459 to 85 restraints in 12 months. ‘Training has meant there is lots more early intervention,’ says Ms Bewsey. 

Continuos drive

Despite such recognition, the drive for improvement continues at Brookside. ‘The model continues to evolve,’ says Ms Bewsey. ‘There are only two stars on our outstanding rating and I want five. 

‘The CQC said our transformation is unprecedented – no service has changed a rating round so quickly. It was a very happy day in my career as now our young people have this brilliant service.

‘The team is amazing, and I am proud of them and the changes they have made to improve nursing practice for young people with mental health difficulties. Winning this award is the perfect acknowledgement of the 18 months of inspiring team work. 

‘Now, we go into failing units and empower other teams. It is not the nurses who don’t want to deliver great care – they don’t get the leadership. Inspire, change these people’s lives. Go nursing.’