INTRODUCTION NHS Wirral by MikeJenny


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                                                                                     Appendix 1

1.   Rosewood Intensive Rehabilitation Unit opened in March 2007 in response to an identified
     need to provide a Rehabilitation service for service users with a diagnosis of severe mental
     illness and complex needs. Wirral PCT and Western Cheshire PCT identified a number of
     service users who were receiving out of area treatments, and as a result of this identified a
     gap in locally provided services.

     15 beds were commissioned by Wirral PCT and Western Cheshire PCT, 5 female beds and
     10 male beds.

        The unit is geographically gender specific, but the design lends itself to flexible usage
         depending on the demand for future male/female admissions.

        All beds are currently occupied:
         A) There are 8 Wirral service users, 5 of which were in out of area placements, 2 on
         acute wards and 1 in medium secure forensic service.
         B) There are 7 Western Cheshire service users, 3 of which were in out of area
         placements, 3 on Acute wards and 1 in medium secure forensic service.

        Rosewood IRU currently has a waiting list of 3 service users, 2 from Wirral, 1 from
         Western Cheshire.

        Rosewood currently has 4 assessments pending, 2 Wirral Service users, 1 Western
         Cheshire, 1 Central and Eastern Cheshire.

        Rosewood is now part of a Trust wide Rehabilitation Service with the lead Consultant
         Psychiatrist, Dr. Ahmed Mahmood, specialising in Rehabilitation.       Dr. Mahmood
         commenced this post in January 2008.

2.   The report contains two anonymous case studies which will demonstrate progress and
     current outcomes for those service users. These can be found in Appendices A and B.

3.   The following report is based on the “Service Specification Mental Health Intensive
     Rehabilitation Service” (Western Cheshire PCT and Wirral PCT 2006) and “The Operational
     Policy for Rosewood Intensive Rehabilitation Unit”. (Cheshire and Wirral Partnership NHS
     Foundation Trust, April 2007

4.   Standard 1 – Effective Care Co-ordination

     Currently there is a five week cycle of rolling reviews of the CPAs (Care Programme
     Approach) for all service users on Rosewood. This process has been in place since January
     2008 following the appointment of the new RMO. We are currently monitoring this and a
     planned audit will take place after 6 months in collaboration with EBPC (Evidence Based
     Practice Centre).

5.   Standard 2 – Involvement of service users and their experience of services.

        Following admission to Rosewood service users were asked to complete a service user
        Rosewood also takes part in the CWP in-patient audit (awaiting feedback from January
         2008 Audit).
        Service users attend a multi-disciplinary daily planning meeting where rehabilitation
         activities for the day are planned and negotiated with the emphasis on choice and

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          meaningful activity which will meet their individual identified needs. The meetings are
          recorded by the service users themselves and minutes are produced.
         Service users also have the opportunity to attend a monthly “community” meeting where
          more general discussions about the unit can take place and information can be shared
          i.e. any developments they would like to see within the unit.
         We are currently in discussions with the EBPC to develop a further questionnaire to look
          at the service users experience since admission.
         Service users have been offered the opportunity to undertake Trust training to assist in
          the recruitment of ward staff but have declined this.

6.    Standard 3 – Involvement of carers

         Rosewood Intensive Rehabilitation Unit holds a monthly multi-disciplinary Carers
          meeting. The aim is to provide peer support, education, information and professional
          support and guidance for carers. All carers are invited and attendance can vary.
         Carers are also invited to share their views at ward reviews and CPA meetings.

7.    Standard 4 – Links with Advocacy

         All service users have access to the Independent Advocacy Service within Bowmere
         Use of the service varies dependant on service user need but is generally used for benefit

8.    Standard 5 - Research and Development

         Rosewood has developed links with other Rehabilitation Units within the Trust and also in
          other parts of the country. We hope to formalise these links and develop a network of
          rehabilitation services to share and develop good practice.
         Rosewood link in with Bowmere hospital as a Practice Development Research Unit which
          is in partnership with the University of Chester.
         Rosewood is recognised as a learning environment for students studying:
          A) Pre and Post registration Nurse training
          B) Medical students
         There is an identified clinical lead for Research & Development.

9.    Standard 6 – Gender Sensitive services

         Male and female areas are completely gender specific on Rosewood.
         There are a number of activities that take place, usually outside of the unit that both
          genders access together, dependant on risk assessment.
         PEAT (Patient Environmental Action Team)

10.   Standard 7 – communication needs of minority groups

      Currently Rosewood has no service users from minority groups. However, staff would have
      access to interpreter services and other resources such as dietetics, spiritual care,
      information leaflets etc. via CWP and would access them as required.

11.   Standard 8 – Staffing, recruitment, retention

       2 sessions Consultant Psychiatrist input per week.
       3 sessions junior doctor input

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      Psychological Services
       3 sessions from Psychotherapy services (including consultant psychotherapist and nurse
       1 session Psychology input per week
       Nursing and Occupational Therapy
       1 Unit Manager
       2 x band 6 Clinical Lead
       1 x band 6 specialist Occupational Therapist
       1 x band 3 Technical Instructor
       14 x band 5 Staff Nurses (key workers)
       2 x band 4 assistant practitioners (currently vacant, identified staff completing Assistant
         Practitioner training who will fill these posts)
       14 x band 3 clinical support workers (1 x vacant)

12.   Each service user has a Care Co-ordinator who remains involved in their care throughout
      their placement on Rosewood Unit and the Care Co-ordinator in-reaches into the unit.

13.   Standard 9 – Training and expertise

         All staff receive twice yearly PDP & PDR (Personal Development Plan & Review) which
          identifies their training and development needs and uses the Agenda for Change
          Knowledge & Skills framework. Their plans include Trust wide essential learning, suicide
          & homicide awareness, CPR and management of violence, Equality & Diversity and
          customer care, recovery and wellness, recovery and action planning (WRAP) training.
         Staff also have access to the Trust training and development department and courses
          provided by the Universities of Chester, Edge Hill & John Moores.
         Staff can apply for more specialist courses, conferences, events through their PDP‟s.
          Following which the unit Manager can produce a bid to the training committee for funding.
         A number of staff have or are being trained in Psychosocial Interventions and Cognitive
          Behavioural Therapy.
         We have a number of staff working as link nurses both within the hospital and with
          outside agencies e.g. CHAPTER (Chester Area Project for Training, Employment & Re-

14.   Standard 10 – Financial Management

         The savings to the PCT in returning five service users from out of area placements in
          2007-08 totalled £134,983
         Total costs of the service are £584,692.

15.   Standard 11 - Service Management

         There have been regular meetings with the commissioners and CWP Management team
          responsible for Rosewood to review the progress and share detailed information. The
          meetings chaired by the Director of Adult & Older People‟s Mental Health services in

         Rosewood has full access to IT as per trust policy. Service user clinical records are fully
          computerised and allow easy access and information sharing within the multi-disciplinary

         Electronic records of referrals and outcomes are kept by the Unit Manager.

         Rosewood does not have any delayed discharges.

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         All activity data (MHDS, bed occupancy) is collected via the Care notes electronic patient
          record system.

16.   Standard 12 – Overview from Trust Board of service delivery, management and

         The Board of CWP were keen to support both Wirral and Western Cheshire PCT in their
          desire to provide local services for local people who had previously been placed out of
          area, or were at risk of being placed out of area.

         The Board, through its capital programme enabled the ward environment to be
          reconfigured to provide a homely, safe and pleasant environment for its residents.

         The philosophy of unit is in keeping with the vision of CWP which enhances mental health
          and well being by working in partnership.

         The evidence from a variety of activities since the unit opened has been positive and of a
          high standard and patients have access to a variety of opportunities to integrate with local

         The staff on the unit are a credit to the Trust and the progress that individuals have made
          are a reflection of the skills and knowledge that are provided by the team.

17.   Standard 13 – Reporting and following up serious and untoward incidents

         All staff adhere to Trust policy for reporting and follows up of serious and untoward
          incidents (SUI).

         The Unit Manager conducts reflective reviews following any SUI or incidences where
          appropriate. The Service Manager/Modern Matron with involvement of Rosewood Unit
          Manager conducts Root Cause Analysis investigations (where appropriate). There has
          been one Category A SUI on 7 November 2007 which tragically resulted in a fatality. The
          cause of death reported post-mortem was confirmed as „laryngeal obstruction due to food
          bolus‟. .

18.   Standard 14 – Delivery of Statutory Duties

         Mental Health Act (1983) administration is provided within Bowmere.
          A) Staff receive training and updates on the Mental Health Act (1983).
          B) Staff also complete reports for Managers Reviews and Mental Health Review
          C) Rosewood received a very positive response from the Mental Health Act
              Commissioners visit in 2007.

         Key workers attend MAPPA (Multi Agency Public Protection Arrangements) meetings for
          service users who are subject to this process.
         A member of staff is nominated as health and safety representative on the unit and
          attends the Trust health and safety meetings.
         Rosewood is fully compliant with the Trusts robust complaints/compliments procedure.

19.   Standard 15 – Security

         There is a CWP Security Policy No. GR8 which Rosewood is compliant with.
         All staff receive child protection and vulnerable adult training and adhere to the CWP child
          visiting policy.
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         There is a designated child visiting room on Rosewood.
         There is an identified link nurse for child protection and vulnerable adults.

20.   Standard 16- The care pathway

         Service users are referred by their Consultant Psychiatrist or Care Co-ordinator following
          discussion with the referring multi-disciplinary team, in the form of a letter, detailing
          service user history and current treatment and presentation.
         Rosewood has developed a referral/assessment form which is currently being piloted to
          ensure standardised information about the service user.
         Based on the information given, a team of senior staff from Rosewood will arrange a
          multi-disciplinary assessment of the service user.
         Following assessment by Rosewood MDT and discussion with the RMO, referrers will be
          informed by letter of the decision as to whether the service user meets the criteria for
          Rosewood. If so a bed will be offered and an approximate time frame for admission given.
          The Rosewood team will also offer advice on management if the service user does not
          meet the criteria for admission.

21.   Standard 17 – Treatments, therapies and rehabilitation opportunities

         All service users have an individualised care plan agreed in collaboration with them to
          address their needs which include mental health, physical health, education, financial and
          leisure needs.
         The Unit has developed a matrix based on NICE guidance to ensure best practice
         Rosewood has built up a network of links with local agencies such as CHAPTER (Chester
          Area Project for Training, Employment and Re-Training), local health and fitness clubs
          and Chester College to increase the opportunities for social inclusion of our service users.
          We currently have two service users who through choice are attending Chester College;
          another is waiting for the course to start in September.
         Chapter are currently linking with one of our service users to develop an individualised
          work placement.
         Each service user has a weekly activity programme (Appendix 2).
         Some service users have also expressed an interest in bike riding as part of leisure and
          fitness programme and Cheshire Constabulary have kindly donated four bikes to the unit
          for this purpose.
         Bowmere is part of the STAR wards national initiative and Rosewood has linked in with
          this project. Star wards works with Mental Health Trusts to enhance acute inpatients‟ daily
          experiences and treatment outcomes. Members of the Star wards network try to
         implement whichever of the 75 practical ideas that are relevant to them and the Star
          wards organisation support with information and resources. Bowmere is one of the few
          NHS Mental Health Units within the country to meet all 75 standards.

22.   Standard 18 – How care is delivered

         Care is delivered in collaboration with the service user through a multi disciplinary
          framework, including medical, nursing, occupational therapy, community mental health
          teams, assertive outreach teams, psychology and psychotherapy staff and where
          possible carers.
         Each service user has a fully integrated care plan.
         A single electronic file for each service user is available 24hrs a day.

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23.   Standard 19 – Environmental and daily living experience

         Rosewood provides a safe, secure and homely environment for both service users and
         The environment complies with key policies such as anti ligature, and has regular
          inspections from the Patient Environment Action Team (PEAT), and infection control
         All service users have single bedrooms with en-suite toilets and showers which promotes
          privacy and dignity.
         There are a number of quiet areas which service users can use for relaxation, visiting etc.
         There is a designated room for child visiting.

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                                                                                        Appendix A
                          Rosewood Intensive Rehabilitation Unit

Mr D is a 23 year old male with a diagnosis of Paranoid Schizophrenia who was admitted to
Rosewood Intensive Rehabilitation Unit from Clatterbridge Mental Health Unit on a Section 3 of the
Mental Health Act in March 2007.

Mr D had started to become unwell at the age of 17, it was noted that his personality had changed,
he was using cannabis and drank alcohol frequently, he became isolated, had fears about
contamination and frequently showered. He became fussy about his food; he was using bad
language, and was talking to himself. He appeared to be responding to auditory hallucinations, was
frequently looking in mirrors, and had run into the street and was irritable with the neighbours. He
moved in with his mother and was noted to have a hatchet in a plastic bag. At this point in April
2003 he was admitted to Clatterbridge Mental Health Unit. He was treated compulsorily with
Olanzipine and improved to the point that he was discharged in July 2003; however concerns
remained about his level of drinking. In October 2003 he was readmitted after stopping his
medication and increasing his use of alcohol and cannabis. He was treated with Risperidone and
was discharged in January 2004. In November 2006 He was admitted again, he was not eating
properly, sleeping poorly and having paranoid ideas. He had been drinking heavily and playing
music loudly. He had been aggressive to his father, was washing his hands excessively and was
opening and closing doors. Relationships with his family had become very fraught. His mood was
incongruous and he was managed with depot medication and fluoxetine. He was admitted to
Rosewood Unit for a period of rehabilitation.

When first admitted to Rosewood Unit Mr D was isolative, he frequently paced in front the mirror
talking to himself and was self harming by cutting his head with a razor. It was felt that he was
responding to auditory hallucinations and he would obsessively wash and shave himself. He would
smoke excessively and would rarely engage in conversation with others. He appeared to be
paranoid and when he did talk his conversation would be limited to alcohol and his desire to drink.
He had the main goal of moving into his own flat in Birkenhead, which was felt to be unrealistic.
Due to his poor concentration his road safety was very poor and so he was only allowed leave
accompanied by staff.

Since admission to Rosewood Intensive Rehabilitation Unit Mr D has improved significantly. He
was commenced on Clozaril and he engaged with his key worker to start a Wellness Recovery
Action Plan, which resulted in a significant improvement in his mental health. His interest in
activities improved, he started to play table tennis regularly with our Technical Instructor and
engage more with other staff. He became more sociable on the unit and would request to go out
shopping or on other outings with staff. He also responded well to the boundaries set by staff; after
initially having his cigarettes allocated by staff, he worked towards managing them responsibly
himself; he is now able to shave independently with no incidences of self harm; he has used his
unescorted leave responsibly in order to obtain unlimited leave around the immediate local area;
and has engaged with OT which resulted with him being able to get the train home unescorted to
Rock ferry. Mr D has also addressed his alcohol misuse and has agreed to limit his use to 2
shandy‟s a week, which he has continued to do in order to progress. In addition Mr D is more
realistic about his future, he has agreed to aim for supported accommodation initially and is keen to
gain employment in the future and so is involved with CHAPTER who are in the process of setting
up a voluntary work placement for him.

Mr D‟s relationships with his family have improved significantly. He has once again become close
to both his parents and maintains regular contact with his siblings. Currently Mr D makes his own
way home to his parents homes and spends two nights a week there. His obsessive traits are
much improved as is his concentration and restlessness. He is not seen on the unit responding to

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external stimuli and he hasn‟t expressed any paranoid ideas. He engages with his rehab plan of
regular cooking sessions with the OT to develop skills, and has worked on his road safety. He
wants to take more responsibility for his money, collecting his benefits from the post office and is
self medicating safely at home. He will request staff support if required and frequently discusses
any anxieties he has. His focus on alcohol is significantly reduced and he is hopeful about his

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                                                                                        Appendix B
                          Rosewood Intensive Rehabilitation Unit

Miss L has been a resident on Rosewood Unit since April 2007 for a period of rehabilitation. She
was transferred from a private sector hospital in Doncaster and is detained under Section 3 of the
Mental Health Act. Miss L suffers with auditory hallucinations and is thought to have an emotionally
unstable personality. She has also experienced depression, anxiety, an eating disorder, self harm
in the form of cutting and overdose, and alcohol dependence.

When first admitted to Rosewood Unit Miss L was Psychotic, she was openly responding to
auditory hallucinations, she was isolative, irritable, her dietary intake was poor and she was very
chaotic in activities, for example she would frequently change her clothes, or dye her hair. She was
considered to be very vulnerable, she had a high risk of absconding and posed a significant risk to
herself, through exploitation or substance misuse, complicated further by extensive damage to her
liver by past alcohol abuse. At the time of admission Miss L was only allowed off the unit
accompanied by two staff.

Since Miss L‟s admission to Rosewood she has improved significantly. She was commenced on
Clozaril which has improved her psychotic symptoms and by gradual rapport building by staff she
began to engage in her rehabilitation programme. She started to attend outings and group
activities and would request staff support to access the community. She began to identify interests
such as shopping for clothes, creative artwork, cinema, walking, dance and activities that relate to
her appearance, e.g. having her hair done, and she started to structure her time more effectively,
i.e. she would get up in time for the morning meeting, request to go to the gym most days and she
may do some art work. She has also demonstrated a responsible use of her leave and is now able
to go around the hospital grounds independently for 20 minutes. Miss L‟s self esteem is much
improved which is evident in her communication. She will initiate conversations and will offer eye
contact. Since admission there has been no evidence of self harm and Miss L‟s dietary intake is
improved. She has cooked irregularly with OT, but has now agreed to a regular weekly session
and she has made enquiries about starting a course at college.

Although the risks around Miss L‟s vulnerability continue to exist, her risk of absconding is reduced
and there has been no evidence of substance or alcohol abuse in recent months. She has adhered
to her care plan of no alcohol and it has recently been agreed that she can have half a shandy
when out, which she has kept to. Additionally, she is less chaotic than she was; she will accept
advice and is more able to think rationally. She is becoming more realistic about her future and is
demonstrating commitment to her goals by engaging in her care plans. Although it is felt that Miss
L has not yet reached her optimum, it is believed that her functional abilities are much improved
and will continue to improve, with her being able to live in her local area in a less supported
placement on discharge, which was once thought unlikely to be possible.

             List of activities available to Rosewood Intensive Rehabilitation Unit

      Gym
      Swimming- (multi sex, female only and male only sessions)
      Badminton
      Computer group
      Wood Work Sessions in the Workshop
      Model making group
      Activity Club
      Music group
      Gardening group
      Fishing group
      Breakfast Club
      Film Clubs
      Bingo
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      Community Outings- Cinema, Pub, libraries, bowling etc.
      Individual shopping and cooking sessions
      Community outings
      WRAP sessions
      Individual Anxiety Management sessions
      Individual Sessions with the Psychotherapy Team
      Art Therapy group to start next month facilitated by Psychotherapy and OT
      Church
      College courses- West Cheshire College
      Voluntary work- CHAPTER

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