KEYNOTE: An Update From the CQC
- Chris Dzikiti Director of Mental Health - CQC
Keith and Andy will talk through the roots and core messages of Towards Safer Services 2022. Towards Safer Services is cross sector strategic guidance to reduce restraint. This will include some reference to some other frameworks and points of good practice. Sharing information, patient involvement, primary and secondary interventions, and collaboration from all parties are of central importance. What should you have completed, top tips, what is likely to be covered in version 2 of TSS?
This presentation will follow Jo’s journey from Architect to service user, and from service user to lived experience Advisor. It is an invitation to collaborate with evidence based, lived experience expertise, and will explore the need for, and potential of, lived experience advisors in the design of mental health spaces.
Jo will provide insights into the involvement process behind spatial planning, furniture selection and art creation in collaboration with art charity Hospital Rooms, and examining the role of lived experience advisors in the design of the new mental health hospitals in South West London.
Our mental health care spaces can hold the tension between providing ‘sense of safety’ and a ‘sense of self’. Surely then, the expertise of users should help to shape better care for the future?
The National Forensic Mental Health Hospital in County Dublin, represents a once-in-a-generation step-change in the design of facilities for mental health services in Ireland. The building was designed by Scott Tallon Walker Architects in association with Medical Architecture. Located on a 10-hectare woodland site, the 25,000m² campus replaces the existing Central Mental Hospital in Dundrum, and accommodates 170 high, medium, and low secure mental health beds. The accommodation is laid out as a series of single storey pavilion buildings around a pedestrianised ‘village green’ which contains peaceful gardens for patient amenity and therapeutic activities. Intuitive wayfinding is achieved through a site-wide narrative of colour, art, and landscaping. The project brief and subsequent design have been heavily focused around providing a safe, secure and healing environment that contributes to a patient`s recovery. The presentation will look at how this has been realised including: • Strategic masterplanning and arrangement of accommodation to optimise the existing topology, mature woodland setting and long coastal views. • Adopting a set of very clear planning principles to manage safety and security, while providing freedom of movement for patients • Addressing the competing requirements of observation with the quality of space, daylight and views • Creating high quality internal environments that will endure • High quality landscaping and space for activity to create community, and a meaningful day for patients • Accommodating differing services and future adaptability through standardisation of design. This new facility sets a new standard in mental health facility design in Ireland and provides an international benchmark from which other nations, including the UK, can use to inform future developments. The presentation will look at lessons learnt from design, delivery and the initial evaluation of performance.
This presentation will focus on the important role played by good landscape design in the creation of therapeutic mental health facilities. Our approach to landscape design in mental health, and a focus on good such design can enhance mental healthcare settings. We all recognise how green outdoor spaces and access to nature benefits our health and wellbeing. Most important is the provision of patient and service user accessible outdoor space. Spending time in nature has been proven to reduce stress, improve our memories, and make us kinder and more creative. Providing accessible sensory and healing garden spaces enhances the sense of wellbeing and helps to reduce stay times in mental health facilities. It is the vital role of the landscape that is the theme of this presentation. Our presentation will cover a number of key criteria as part of this placemaking process as well as covering the important clinical requirements of providing therapeutic and sensory spaces that encompass safety and security in a much more creative way to avoid places feeling institutional.
Having worked for the Trust in IT for four years I'm a person with lived experience and I also have A physical disability, I'm at the centre of the programme's day to day running. I have real responsibilities and I am involved in making key decisions. I have attended all the design engagements and design meetings across the programme. I feel listened to and able to offer feedback and advice. I've been a vessel for service users and carers across our services to be involved, giving feedback on how they'd like the buildings to look and feel.
Sussex Partnership is a mental health and learning disability NHS Foundation Trust in South East England. In 2020, a project was proposed to work with hospital staff to create 'Autism Friendly' environments on acute mental health wards, by primarily looking at the Environment; the Ward Processes; Staff Training and increasing Confidence. This was due to recognising the high number of autistic service users who had reported that the environmental and sensory aspects of their admissions had negatively impacted their wellbeing and inpatient experience.
Two pilot wards were selected: an 18-bed female acute mental health ward and a 19-bed mixed sex acute ward in Sussex. Both wards support adults aged 18-65 with mental health needs, who require inpatient care and treatment.
A sensory audit of the ward environment was completed by two Occupational Therapists (OTs) and a group of Experts by Experiences (EbEs). The EbEs all had experience of admission. Photos were also shared with another OT and further EbEs and The 'Checklist for: Autism & Mental Health-Friendly Environments' was used to help facilitate discussions around the senses and experience of each area of the wards.
The team worked to develop environmental recommendations considering the senses (visual; olfactory; auditory; proprioception/body awareness; tactile; gustatory and vestibular). These were shared with management and estates teams to implement these recommendations safely and efficiently to achieve our goal of creating 'autism friendly' environments. The project coincided with ward refurbishment projects and therefore the recommendations were able to be incorporated as part of the general refurbishments.
By collaboratively working with the group of EbEs, this kept the service user experience in the centre of the project, and challenged all involved to think differently. It is felt that the recommendations are meaningful and already having a positive impact for service users within the mental health wards.
This Presentation from Scottish Government Assoc. Chief Nursing Officer Mark Richards (and potentially Susan Grant Principal Architect NHSScotland) is on the development and pilot of a new tool to assess the quality and safety of NHSS mental health estate environments.
It is an update of NHSScotland's 2022 DIMH Conf presentation on self-harm reduction learning from Scotland, which recommended the above tool development. July 2022 Scottish Government Mental Health Directorate created a multi-agency & disciplinary Short Life Working Group to enable delivery of an environmental assessment tool specific to the mental health estate.
Group stakeholders include clinicians, people with lived experience, facility and design professionals, and health and safety experts. The work of the group will be underpinned by consideration of a literature review focused on the impact of mental health facility design on service users and staff. Initial pilot testing of the tool is due Spring 2023.
We selected: 3. Policy, Research and Standard, as this tool will likely be a mandated 'Standard' following pilot via a new NHSS Guidance publication (e.g. HBN / SHPN). However, this specific presentation actually encompasses all 8 of the conference themes, and therefore is likely best suited to a keynote session.
Stonebow - Acute Adult Inpatient Hospital Hereford
We spent a day talking to staff and patients to understand the challenges faced by the current service. We are carrying out some design and construction work to improve the unit and are gather some thoughts and views on how we can make the ward environment better. We will follow up with a staff and patient survey based on the observations to benchmark the improvements works will make by revisiting the unit once the works are complete for feedback and to collect evidence measures. Carrying out this process will help understand how design can impact and make improvements on the working and living environment.
The study has captured thoughts and views against the following categories
- Privacy and dignity
- Staff culture
The design opportunities in response gives areas for qualitative and evidence measures that can be captured through desktop studies and feedback forms for staff and patients.
There are three patient groups for the study
- Mortimer ward 21 bedded Adult Acute
- Jenny Lind 8 bedded mixed Older Adult Functional
- Cantaloupe ward 10 bedded Older Adult Organic
We design our built environment and the places we inhabit to meet a series of technical standards, developed to accommodate diversity through built form and to provide spaces that support physical ability, motor, visual and auditory impairments.
In developing truly inclusive environments, we need to support the mind and the needs of people who experience sensory and neurological differences. Designing for the mind should be considered an enriching and integral part of the design process.
This presentation will investigate Neurodiversity and its complexity with unusual insights revealing some of the enhanced abilities and extraordinary skill sets of this group. How can design underpin Neurodiversity by creating inclusive spaces that support health and wellbeing in our community and as individuals?
Will we be choreographing environments to be sensorially and technologically responsive as well as adaptive to multiple neural and sensory landscapes. Could we benefit from such design tools as Hypo/Hyper Sensory Scales, Emotional Mapping, Sensory Plans, Proxemics and Sense Sensitive Design supported by Evidence Based Research. Where would these insights take us? What does good look like in tomorrow's new world of design?
On July 16th 2022, the 988 Crisis Hotline will activate, allowing a nationwide network of crisis centers & support facilities across America to respond in concert.
With the funding provided by the Behavioral Crisis Services Expansion Act, among other bills recently passed and soon to be signed, we've prototyped design and planning approaches for the evolving mental health crisis system in the US.
At the time of this submission , some communities will only use the 988 number as a standalone hotline. Approximately 60% of communities will have a plan to coordinate with clinical care organizations or providers in some capacity.
Of these, a mere 28% of communities will have access to urgent care units for mental health or similar facility services.
Emergency Departments across the US are often crowded and ill equipped to treat this vulnerable patient population. It is all too common to hear that a patient can spend days in a small 10'x10' secure holding room with no access to daylight or nature. Thankfully, health systems and public policymakers are responding to these trends. Government funding for treatment programs and medical research has increased over the years, with billions allocated for the Substance Abuse and Mental Health Services Administration (SAMHSA) to implement crisis stabilization efforts, resulting in greater capital investment in behavioral health facilities by health systems nationwide.
This has catalyzed a growing trend of standalone Psych EDs and Crisis Stabilization centers across the country to divert these cases from hospitals or law enforcement settings to more appropriate, therapeutic environment.
This "Alameda" approach has proven that these high-functioning crisis response centers can eliminate ED boarding as well as increase access to care while decreasing wait times, resulting in fewer inpatient admissions (up to 75%) and overall decreased health costs. Stantec is on the forefront of designing behavioral and mental health facilities that lessen stigma, challenge barriers to treatment and social determinants of health. The need for patient-centered, cost effective, empathetic care drives our behavioral health practice today.
Attendees will learn how applying evidenced-based behavioral health practices can lead to better outcomes and shorter lengths of stay. Architecture and the built environment can support best practice medicine and a patient in crisis by creating calming environments with a focus on de-escalation, not re-traumatization. Increasingly, designers and planners employ Trauma-Informed design principles to create spaces for patients that have a sense of dignity, respect, control, safety, and a connection to their community.
The session will cover trends that have manifested in US-based FGI 2022 guidelines for behavioral health crisis units following the "EmPATH" model. The EmPATH model is a concept that focuses on treating "patients in a calming, living room setting" with artwork, natural light, and sensory rooms" (Hoff). This dovetails with the use of subacute inpatient settings for crisis stabilization, which is often driven by the 16-bed count, below the regulatory threshold that more acute settings require. It is not uncommon to see multiple 16 bed "buildings" on a small campus or other distinctly separated in a facility to overcome this hurdle.
These are just a few design concepts for crisis diversion facilities we'll highlight from across North America.
Focussing on the design and use of commercial, public and residential buildings the new BSI guidance document PAS 6463 Design for the mind (Neurodiversity and the built environment) recommends ways to make spaces accessible and inclusive to people who have differences in sensory processing. This may include people have been assessed as neurodivergent, people with a brain injury or those with a neurodegenerative health condition. Many others without a formal assessment are also negatively affected by the sensory impact of buildings.
This makes up a significant number of our population who may find buildings uncomfortable or difficult to use
Sensory overload is often a contributing factor; it raises stress levels and increases cognitive load, leading to anxiety and, in some cases, poor physical and mental health. Sound is often a key element in sensory overload and so acoustics and noise management forms an integral part of the PAS document
This presentation references the acoustic detail from the PAS guidance and uses example from refurbishment projects in public spaces including an interactive science museum, a children's centre and a community hall to showing in a practical way how good acoustic design can reduce or eliminate noise challenges, so helping to create places which are easy to use and where people can flourish.
Funding has been given by NHS England to make inpatient wards more therapeutic for people on the autistic spectrum. Many autistic people have sensory difficulties, where they are over-sensitive or under-sensitive to the world around them. The project is intended to focus on four wards to create change which can be applied across the remaining 50 plus wards in the Trust. The project will run from September 2021 to October 2022.
Organisations who are partners in the projects
Experts by experience (EBE Network) - To be part of the Task Force group to over see the implementation of changes.
Autism West Midlands - To deliver training to bring the experience of inpatient wards for people with LDA to life for ward teams.
Estates partners internal and external - To support estates solution and take forward practical changes to the environment.
Birmingham and Solihull CCG
The project aims to improve four (3 acute) inpatient ward environments to improve service user and family experience and clinical outcomes. It is also expected that paying attention to sensory impact will reduce distress and restrictive practice and improve the experience of care. The project has 4 main stages.
1 -Training of staff and the wider multi professional team to increase their awareness, knowledge, and skills in understanding the sensory impact of a ward environment and an ability to develop and put in place simple strategies to support patients in their recovery. This will also include identifying and training key staff to further increase skills to take a lead in the future.
2 -Establishing a task force (working with EBEs, current inpatients, external experts, estates team and the wider staff team) to identify and make changes to the ward environment. These changes will include the addition of equipment and physical adaptations to the environment.
3 -Making the changes and maintaining the momentum through a regular task force group and local weekly ward meetings.
4 -Measuring and understanding the impact of changes and sharing learning. The Trust use a quality improvement methodology which is suited to measuring the impact of the changes to allow learning and sharing across the Trust.
Many of our inpatient staff lack knowledge in this area and are therefore missing opportunities to make simple changes to reduce the negative impact of a ward environment. The project will seek to enhance staff knowledge and skills, identify, and deliver changes which will improve the environment to respond to the needs of service users in particular those with autism and / or learning disability whose recovery could be adversely affected by the environment. It is believed that through increasing our understanding of the experience of people with autism /LD we can make practical changes which will not only reduce distress, but also reduce restrictive practice improving the effectiveness of treatment, reducing length of stay and improving the experience of service users and their families.
Much of our estate is older and has not been designed with sensory considerations in mind and the physical environment can create stress due to noise, light, and a lack of soft furnishings. We believe this will also support the recovery of service users who do not have autism or LD and the well-being of staff who work in the ward setting.
Improved service user experience in an inpatient ward
Improved co production and a better understanding of the needs of individuals with autism and / or LD
Improved environment reducing distress and creating a calmer more therapeutic environment.
Reduced restrictive practice ie seclusion, restraint etc
Reduced incidents of self-harm, violence
Improve understanding of staff about the impact of the environment and how to regulate this for the benefit of all
Improve staff satisfaction and morale about working more effectively with this client group
There have been various change ideas that have been implemented
The provision for quality mental health facilities within our urban environments is a challenge many of our healthcare providers face. As our cities grown in scale and population, so do the mental health needs of residents - but how can we provide therapeutic, healing environments amongst the noise, chaos, and commotion of our urban settings?
Drawing on our work at the Pears Maudsley Centre for Children and Young People, we'll look at how we overcame the constraints of a dense urban site.
- Recognition of the requirement for densification for urban healthcare sites due to the worsening condition of the UK's mental health crisis. The growing mental health crisis in cities demands vast expansion on clinical mental health provisions. The existing building stock of the SLaM is no longer fit for purpose due to required growth in CAHMS services, with an estimated one in eight children suffering with mental health issues today.
- Explanation of the collaborative methods between clinicians and researchers which aim to reduce the requirement for projected physical expansion of estates. The Pears Maudsley Centre is designed as a collaborative hub accelerating the pace and societal impact of translational research offering a shift to preventative, as opposed to reactive treatment methods.
- Exploration of a design approach which enables both the densification of a site whilst retaining therapeutic environments and a connection with nature, and how a building with a briefed area of almost four times the area of its site can still meet the clinical requirements for a healthy and therapeutic environment.
'HBN 03-01 Adult mental health units: planning and design' states that 'Ground floor ward accommodation is recommended' but does not provide any further qualification. In this presentation, Mark will discuss principles and assumptions, drawing on a range of case studies that explore approaches to ground floor and multi-storey mental health accommodation, to test this statement.
Mark will review potential implications if the guidance is always taken at face value, and mental health inpatient accommodation is only provided in a single storey. These include:
• Cost and affordability
• Capacity, development density and site context
• De- stigmatisation of mental health services
Mark will also review some of the common challenges associated with multi-storey mental health that have contributed to the provision of the guidance. These include:
• Autonomy and access to outdoor space
• Safety and security (including fire)
• Staffing models
He will then demonstrate how these challenges can be overcome through thoughtful mental health facility design, drawing upon recent case studies that demonstrate cost-effective multi-storey mental health facilities that provide a therapeutic environment for the recovery of patients.
This includes evaluation of the performance of the Blossom Court inpatient unit at St Ann's Hospital which opened in 2020. The two-storey arrangement sees four wards stacked around two terraced courtyards, creating a therapeutic environment which promotes direct and independent access to outdoor space on both floors. Since completion, the Trust has reported that compared to the previous accommodation, seclusion and rapid tranquilisation of patients has significantly reduced, while physical restraint has almost entirely stopped, allowing better focus on the recovery of patients.