Part 1
The Strategic Case (1)
Appendix 2A
Appendix 2B
Appendix 2C
- Programme Stakeholder & Consultation
- Clinical Brief
- Environmental Quality Report
Appendix 2A
Programme Stakeholder and Consultation
Programme Stakeholders and Consultation
NHS Ayrshire & Arran has involved a broad range of stakeholders in respect
of this programme and in the wider context of healthcare delivery in Ayrshire
through Mind your health, the strategic review of mental health services in
Ayrshire and Arran referred to above.
The Mind your health review was launched in December 2006 at a multistakeholder conference in Ayr attended by around 200 people. Following a
participative approach involving eight multi-stakeholder workshops, two multistakeholder conferences and work by nine multi-stakeholder working groups,
the Board endorsed an overall model of care at its meeting on 23 January
2008.The Board also ratified the proposed approach to planning inpatient
mental health services to include an option appraisal and gave approval to a
programme of informing and engaging with the wider community about the
proposed community based services, from February to May 2008.
During February and March 2008, four reference groups; carers, service
users, voluntary organisations and a fourth group comprising NHS staff,
partner agency representatives and members of the public, carried out an
option appraisal of a previously identified long list of options for the future
location of acute mental health inpatient services. The option appraisal
resulted in a short list of four options, plus the status quo. At the conclusion of
the option appraisal and the period of informing and engaging, the NHS Board
agreed at its meeting on 2 May 2008, to a plan for formal public consultation
on the short list of options for the future location of acute mental health
inpatient services.
The formal public consultation about the future location of acute mental health
inpatient services began on 19 May 2008 and continued through to 12
September 2008 through several mechanisms:
14 community focus groups held throughout Ayrshire and Arran, each
with up to ten people taking part in structured discussions. The focus
groups were widely advertised in the local press, by posters at
community and NHS locations and by invitation letters to over 700
community organisations;
19 targeted focus groups for specific organisations or community
groupings, for example, young people, older people, BME communities
and voluntary bodies
Consultation with NHS staff and professional committees, this included
attending 18 open staff meetings, 16 department meetings and 11
Professional Committees
Consultation with MSPs, MPs, NHS Health Boards, Community
Planning Partnerships and Local Authorities
Attending meetings and events organised by other organisations
throughout Ayrshire
Poster information displays at twelve hospital sites throughout Ayrshire
This approach involved over 2,000 people in active participation and led to the
overwhelming recommendation from all key stakeholder groups that future
acute adult mental health inpatient services should be provided from the
Ayrshire Central Hospital site at Irvine. A formal evaluation process
1
undertaken by an independent section of NHS Ayrshire & Arran and
monitored by the Scottish Health Council, confirmed a very high level of
customer satisfaction with the engagement processes used.
Following completion of the Mind your health review, consultation with
stakeholders has continued as outlined below:
A Mental Health Services Public Reference Group (PRG) was
established in the spring of 2009, supported by the mental health directorate
and comprising service users, carers and interested members of the public –
a total active membership of around 25, with a total membership base of 48.
The PRG meets approximately monthly, and is the main channel of
dialogue between mental health services and service users & carers. Its
activities cover the whole range of mental health services and include regular
updates about the progress of the new build hospital project at Irvine.
Two members of the PRG are nominated as members of the NACH
Public Reference Group, and regularly report back to the PRG.
NACH Public Reference Group
The NACH Public Reference Group was established in June 2009 to
give an opportunity for the local community to comment and contribute to a
range of aspects of service delivery within the site.
To generate interest in a group, over 130 direct invitations were issued
to the local community and voluntary organisations, service users, carers and
the public who had already been in contact with NHS Ayrshire & Arran during
the Mind your health consultation exercise. In addition to the invitations, a
press release and a paid advert in the local press were used to raise
awareness of the open meeting.
The open meeting was held on 29 June 2009 and was attended by
over 80 members of the public. At the meeting NHS Staff outlined the need for
a public reference group, the role of the group, provided background
information on the development and the current proposals for the Ayrshire
Central site and then asked for attendees to “sign up” to get involved.
56 members of the public requested to be nominated for the Public
Reference Group.
It was recognised that there was a need to reflect a balance between
individual, local residents and those representing voluntary/community groups
on the Public Reference Group and from the list of 56, 20 members of the
public were proposed. The remaining members are provided with updates on
the development.
Two representatives of the mental health services PRG attend, thus
facilitating interaction. Video conferencing to a small number of the Island of
Arran community is also provided.
2
So far, the group have commented on the design statement, design,
planning guidelines, benefits realisation, naming of the facility, etc.
It is intended that the NACH Public Reference Group will continue to
meet throughout the design, development and construction phases of the
programme.
Staff
Consultation with NHS Ayrshire & Arran staff has continued through the
periodic issue of “Stop Press” bulletins, sent to all staff, and through the
involvement of many staff in the organisational and operational decisions
relating to the development.
3
Appendix 2B
Clinical Brief
North Ayrshire Community Hospital
Clinical Brief
Supported by:
BUCHAN
ASSOCIATES
TD
Version OBC Final
November 2011
1
Contents
1.
Strategic Context ......................................................................................... 3
2.
Facility Overview ....................................................................................... 10
3.
Schedule of Accommodation .................................................................... 24
Appendices .......................................................................................................... 25
Appendix A – Visual Clinical Specification ........................................................... 26
Appendix B - New Build Adjacency Diagram ....................................................... 35
Appendix C – Schedule of Accommodation ......................................................... 36
Appendix D – Adjacencies Matrix ........................................................................ 37
Appendix E – Ground/Upper Floor considerations............................................... 38
Appendix F – Central (Walk-in) Entrance ............................................................ 39
Appendix G – “Ambulance” Entrance .................................................................. 52
Appendix H – Consultation & Interventional (Outpatients) Area .......................... 61
Appendix I – Multi-function ECT/Minor Surgery/Therapy Area ............................ 79
Appendix J - Pharmacy/Dispensary ................................................................... 103
Appendix K - Tribunal/Meeting Area .................................................................. 111
Appendix L - Acute Mental Health Wards .......................................................... 123
Appendix M - Intensive Psychiatric Care Unit (IPCU) ........................................ 142
Appendix N - Addictions Ward ........................................................................... 161
Appendix O – Forensic Rehabilitation Unit (Low Secure) .................................. 183
Appendix P - Rehabilitation Unit (Adult Mental Health) ...................................... 206
Appendix Q - Elderly Mental Health Wards ....................................................... 227
Appendix R - Rehabilitation Ward (General Health) .......................................... 253
Appendix S – Long Term Care (continuing care) ............................................... 266
Appendix T - Support Clusters ........................................................................... 278
2
1. Strategic Context
a.
NHS Ayrshire & Arran’s Estate Strategy
The Estate Strategy for NHS Ayrshire and Arran and has been developed
to reflect the changing demands on the estate. The Board is committed to
constantly reviewing the services that are needed and planning for the
future needs of the local population. This Estate Strategy sets out how the
estate will be developed to meet those challenges to provide the most
appropriate buildings and estate at the right time and to the right standard.
The benefit to the Board of having this Estate Strategy is an assurance that
the quality of healthcare services will be supported by a safe, secure and
an appropriately built environment.
The overall aim of this document is to provide a concise, user friendly
working document containing information on the existing estate, whilst
identifying the strategic changes that will have a direct impact on the shape
and use of the Board’s estate.
The Estates Strategy is dependent on effective clinical planning and
engagement and as such this has been integral to its development.
Specifically the Estate Strategy provides:
•
A clear, positive statement to public and staff on the Board’s plans to
maintain and improve services and facilities, in line with delivering
its strategic objectives
•
An assessment of the key drivers for change and alignment of the
estate to support the Board’s Service Strategy
•
A strategic context for the forward investment of capital on the
Board’s estate
•
A means by which the Board can identify capital projects and estate
changes that will require formal approval
•
A commitment to sustainable development, environmental targets
and statutory requirements
•
An assurance that risks are controlled and investment targeted to
manage and reduce risk
•
An assurance to staff that they will have an appropriate working
environment
3
Fig.1. Ayrshire Central Hospital: Aerial View
This briefing document describes the clinical requirements of the new
estate to be created that will form part of this important development and
how this must relate to those buildings that it is planned to retain. It is
consequently presented in a number of different sections that broadly relate
to:
•
•
•
•
The strategic context
An overview of the facility, including service/design principles,
concepts, relationships, etc
More detailed descriptions of individual components as presented by
key clinical and support staff (Presented as Appendices)
The proposed schedule of accommodation (Presented in Appendix
C)
It should be noted that this clinical brief relates mainly to clinical
considerations around the new build element of the proposed scheme and
the services being refurbished on Ailsa site. It should be noted that it is only
one component of a wider suite of documents presented in the business
case and should be read in conjunction with these.
4
b.
Demography
The latest available statistics indicate that the estimated total population of
Ayrshire and Arran as at 30 June 2010 was 366,860 a decrease of 0.5 per
cent since 2000.
http://www.gro-scotland.gov.uk/statistics/theme/population/index.html
Figure 1 : Catchment Area for North Ayrshire Community Hospital
The table below shows the projected population change for each local authority.
The decreases in the population within the younger age groups compared to the
increases in the older age groups are very clear for each area.
•
Projected population change for each local authority
Age
(years)
East Ayrshire
North Ayrshire
South Ayrshire
Under 15
- 7.8%
- 15.3%
- 5.1%
15 - 64
- 6.6%
- 12%
- 9.1%
+ 26.6%
+26.6%
+ 20.5%
0.0%
- 4.3%
- 1.2%
65 and over
Total
5
Life Expectancy
The Table below presents data that shows the improvements in life expectancy
between 1997-99 and 2007-09 at the national, health board and council area level.
In Ayrshire and Arran, life expectancy at birth has increased by 1.8%, from 75.5
years to 77.2 years. This is lower than the Scottish average of 77.8 years. East
and South Ayrshire show a similar percentage increase in life expectancy of 2.6
and 2.7 per cent respectively. North Ayrshire shows an increase of 1.9 per cent
over the same period. South Ayrshire has the highest life expectancy, a
significantly older population with fewer areas of multiple deprivation than East
and North Ayrshire. NHS Ayrshire and Arran’s rank position, compared with the
14 NHS Boards has dropped in the time period from 11 to 12. East Ayrshire’s
rank position compared to all other 32 local authorities remains the same however
North Ayrshire has dropped four places to 26th and South Ayrshire has moved
down two places to 17th.
Life expectancy at birth in Scotland 2007-2009 by administrative area, and
comparison with 1997-1999 (persons)
Scotland
Ayrshire and Arran
East Ayrshire
North Ayrshire
South Ayrshire
2007-09
Years
77.8
77.2
1997-99
Years
75.5
75.5
2007-09
Rank
12
1997-99
Rank
11
Difference
in years
2.3
1.8
%
change
3.1
2.4
76.7
76.7
78.4
74.8
75.3
76.4
25
26
17
25
22
15
1.9
1.4
2.1
2.6
1.9
2.7
Ref link http://www.gro-scotland.gov.uk/press/news2008/latest-lifeexpectancy-figures-announced.html
As the population gets older and the demand for NHS services increases, it
is necessary to continue to consider and change how healthcare is
provided in order to respond to the health needs of the population and new
national policies. Services need to be developed to anticipate and manage
long term illness, reduce the need for patients to attend an acute hospital
and avoid unnecessary admissions.
This Clinical Brief takes account of all of the foregoing population and
health issues and is critical to NHS Ayrshire and Arran being able to
respond to these demands.
6
c.
Health Strategy
NHS Ayrshire & Arran has developed a high level vision for the future
direction of clinical services delivery.
This vision is based on shifting services from hospital to community based
delivery (including community hospitals and community treatment centres)
wherever safe and practical to do so and to accommodation fit for purpose.
At the core of this is the national Quality Strategy. Those services that need
to be on a major hospital site would be focused on the two acute sites in
Ayrshire & Arran, with consequent clinical synergies, optimisation of
expensive infrastructure and economies of scale.
This overall vision has now been developed into a number of new
sites/developments including the provision of a new community hospital in
Girvan plus extensive refurbishment and reconfiguration along with
extensions to the main acute centres at Ayr and Crosshouse hospitals as
well as the development of new community resource centres and primary
care services such as dental centre.
Specifically, the evidence available identifies that the case for change
related to healthcare delivery in and around North Ayrshire that is
fundamental to the planning and creation of the proposed North Ayrshire
Community Hospital can be summarised under a range of key headings
including:
•
•
•
Environmental Quality: Whilst clinical care is of the highest quality,
further clinical development in North Ayrshire is currently constrained
by the limitations of the existing built environment, for example, the
majority of the buildings on the Ayrshire Central Hospital site where
clinical care is provided are ageing, functionally unsuitable and in
poor physical condition. Specifically, in the Board’s Property
Strategy, Ayrshire Central Hospital is listed as Estate Code category
C (below acceptable standards) for functional suitability and
category 3 (adequate) for space utilisation.
The Need to Develop New Services & Models of Care: A Clinical
Options Group, set up to ascertain current clinical activity and
proposed services to be delivered from the new hospital has
identified the need to expand the range of services currently on offer
and to review the ways that these are delivered. Although much of
this can be achieved through more detailed analysis of existing
services and operational re-configuration, an element of new build is
required to support future capacity requirements and approved
7
clinical strategies.
•
•
Strategic Fit, including national and local strategy & policy: The
development of services in North Ayrshire must be consistent with
the proposals contained within a wide range of national and local
strategic documents for example :o The Quality Strategy
o ‘Developing Community Hospitals, A Strategy for Scotland’,
o NHS Ayrshire & Arran’s Local Delivery Plan
o Mental Health Local Strategy “Mind Your Health”.
o The Dementia Strategy.
o Reshaping Care for Older People
o Realising potential - An Action Plan for Allied Health
th
Professionals -June 15 2010. This three-year action plan
reflects the focus of key policy initiatives providing support for
the change agenda in mental Health.
•
In summary the new facility should support the Scottish Government stated
purposes of:
•
•
•
•
•
Helping people to sustain and improve their health, especially in
disadvantaged communities, ensuring better, local and faster access
to health care.
Helping local communities to flourish, becoming stronger, safer
places to live, offering improved opportunities and a better quality of
life.
Supporting teaching and training
Rationalising the existing estate in order to improve operational
efficiency, communication, accessibility, etc
8
d.
Bed/Service Modelling
The range/volume of services specified/scheduled within this document are
based on agreed service modelling data. This modelling data has been
generated from a wide range of reviews including:
•
•
•
Detailed current and future bed modelling related to all services
A detailed analysis of all current and future outpatient activity as well
as the services/locations available to support this
A review of current and future office, meeting and administrative
requirements in the context of new buildings and retained estate
All data collected/reviewed has been analysed in the context of existing
local and national strategies on a single, service-wide health/social services
perspective to ensure the provision of appropriately sized/configured areas
that recognise current and future service delivery trends.
Although deemed to be robust, this data does not in any way negate the
requirement for the new facility to be as flexible as possible to meet as yet
unknown future care needs/trends.
Specific planning data/assumptions are included in the individual service
templates presented as Appendices.
9
2. Facility Overview
a.
Retained Estate
The new North Ayrshire Community Hospital facility will feature a significant
new build element that is described within this document as well as an
extensive retained estate. Services that will continue to be delivered from
retained estate but will form the overall community hospital some examples
include:
•
•
•
•
•
•
•
•
•
•
Physical Rehabilitation (Including Pavilions 10 and 11 and the
Douglas Grant Rehabilitation Unit)
Sexual and Reproductive Health
Community Dental Services
Out of Hours Doctors
Diagnostics
General outpatients
Administrative and meeting areas
Offices, including clinical staff offices
Support services, Training & Education Centre
Kitchen and dining areas, including those associated with staff and
patient meal preparation and staff dining areas
It is consequently noted that creating the optimal relationship between new
and retained facilities is seen as a key design challenge associated with
this project. Specifically, the whole facility must be seen and operate as a
cohesive unit, with appropriate external links and FM routes identified with
existing facilities . as represented in the adjacencies diagram. (Appendix B)
This challenge is made all the more difficult when recognising the wide
range of different patient groups that will eventually be located on the site,
many of whom have very different care/environmental needs.
It is further noted that a number of additional projects related to North
Ayrshire Community Hospital have recently been undertaken and that the
impact of these has been factored into all planning assumptions. These
projects included (but are not restricted to); refurbishment of the existing
“Horseshoe” Building, an extension to the existing General Out-patient
Department (OPD), provision of a new Kitchen/Dining Room and
development of an Out of Hours Treatment Facility/NHS 24 Satellite
Control Centre within areas of the existing Horseshoe building.
10
The scheduling and implications of all of these developments must be
taken into consideration during the planning and implementation of this
project.
b.
New Build Component
The new build component of the North Ayrshire Community Hospital, as
identified in the attached Massing Diagram (Adjacencies Diagram B) and
Schedule of Accommodation (Appendix C) will include:
•
A main entrance with reception areas, waiting space, security/porters
accommodation, café, small retail outlet, toilets, spiritual care area,
and other supporting space as appropriate.
•
An in-patient ambulance entrance to support the admission/transferin of patients on trolleys/chairs (avoiding main public thoroughfares).
•
Outpatient clinic/consultation areas configured as a range of interconnected but self-contained “modules” to support the full range of
mental health and psychology-related OP/consulting activity on the
site including Adult speciality area and a child & adolescent area. It
is noted that “general out patient consulting” will continue to occur
within the existing outpatient department although there will also be
a cross-over in activity terms between the two areas.
•
An ECT/Minor surgical/outpatient area, located close to elderly
mental health wards and outpatient areas, with treatment and
recovery spaces that would also be used as clinic accommodation
for AHP services and as a minor surgical procedures area.
(Functions changing on a sessional basis)
•
A pharmacy/dispensary area
•
A tribunal/ meeting area that is easily accessible from the main
“core” of the facility that can be used as meeting rooms when not
being utilised for tribunals
11
•
In-patient ward areas arranged in 3 clinically appropriate “clusters”
around shared re-enablement and rehabilitation areas including:
•
•
Cluster 1; 60 Acute mental health beds in 3 x 20 bedded wards,
Cluster 2; 30 Mental health beds forming a Rehabilitation Unit, 10
addictions beds with day case facility,
Cluster 3; 30 elderly mental health beds in 2 wards, 30 long-term
(continuing) care frail elderly beds and 30 frail elderly rehabilitation
beds
•
•
In addition self contained 8 bedded Intensive Psychiatric Care Unit
(IPCU) and 8 Forensic Rehabilitation/ low secure beds which will use
Cluster 1 rehabilitation and re-enablement accommodation if
required on a planned basis to meet specific patient needs
It is noted, that in developing the operational model for the facility, a
number of principles have been established that need to be recognised in
the design, layout and configuration of the new estate and how it relates to
existing/retained buildings. These include that:
•
Wards should be configured in identified “clusters” in line with the
massing diagram, with each cluster supported by a small range of
local services and support accommodation.
•
Although a number of wards have very similar scheduled
accommodation – primarily to ensure optimum future flexibility – their
preferred layouts, as described in the attached appendices
generated by clinical services can be very different in recognition of
specific clinical needs/considerations.
•
All clinical (outpatient) consultations at the new North Ayrshire
Community Hospital will take place in designated clinical consulting
areas that will be separate from staff offices. These clinical
consultation areas will include the existing general and specialist
outpatient departments within the Horseshoe building, the new
consultation areas specified within the schedules of accommodation
for mental health/psychology/LDS/Etc, related services (including
children’s services) and identified consulting space within wards and
support “clusters”.
•
All office accommodation, including the majority of meeting rooms,
with the exception of a small number of clinical managerial offices
within the scheduled new build, will be located within retained estate
mainly within the Horseshoe Building.
Staff will use the exisiting dining room and new café for all meals
and breaks, with no local staff areas being provided out with this
central “hub”.
•
12
•
The new kitchen area will service all meal requirements throughout
the site and is detailed in the FM Strategy.
•
Staff Changing is based on a model that will see staff only having
access to lockers for the period of a shift/duty in line with current
thinking on this issue and to ensure optimal use of all areas. No
other staff changing facility will be provided on site.
•
The majority of support services functions will continue to be
delivered from existing locations on the site. The only exception to
this being the inclusion of a porter’s area, security office, cashiers
function and limited support areas in the new building.
•
Control of infection issues remain extremely important
considerations with Domestic Services Rooms (DSR or “Cleaners
rooms”), linen areas, clean utility rooms and dirty utility rooms
specified in all areas. Whilst efficient design may allow some
appropriate sharing of these facilities, the design should always
optimise the control and management of Hospital Acquired Infection
in line with all relevant guidance on this matter, most notably in line
with HAI SCRIBE.
•
Future flexibility of all accommodation and, in particular, the ability of
new spaces to be easily changed with time with regards to
boundaries, layouts, patient groups using and clinical models
employed is paramount.
•
The overall design and layout of all areas should aim to reduce the
risk of harm to patients and staff. Key elements of this risk reduction
strategy should include, but not be restricted to:
o Ligature points being avoided in all clinical/common areas
through the selection of fittings and materials that reduce risk
o Door handles must not have thumbscrews
o The clinician should be positioned closest to the exit door of
the room when consulting with or treating a patient
o Wall mounted ‘up and down’ lighters should be used rather
than angle-poise lamps for bed positions
o Sharp edges should be avoided
o Wall mounted items of equipment such as fire extinguishers
should be recessed to prevent damage
o Wall / door protectors should be used where there is risk of
damage from e.g. bed / trolley movement
•
In addition, it is noted that it should be possible for staff to lock-off
en-suites, manually override any locks applied by patients and
isolate utilities such as power or water from out with the room as
appropriate
13
Overview: Entrances & Common Areas
The technological nature of hospital services may be an stressful
experience for patients and their relatives. It is important, therefore, that
when designing these facilities that the overall patient experience is taken
into account together with that of their relatives, carers and visitors. The
emphasis should be on providing a comfortable, pleasant but safe
environment for patients and staff wherever possible, with particular
emphasis on the wider therapeutic elements of the design and finishes.
The ethos and philosophy is dominated by models for ‘Recovery’ ‘Reenablement’ and ‘Rehabilitation’ as this is not a district General Hospital.
It is also essential to consider the needs of staff and the impact that the
working environment has on job satisfaction, recruitment and retention.
Addressing gender, cultural and religious diversity is also a consideration
as are the needs of relatives, carers and visitors whose opinions must be
sought throughout the design process and taken into consideration.
Additionally, consideration should be given to alleviating fear and anxiety,
maximizing security and safety, reducing boredom and creating a healing
environment with the need for artwork, designed furniture, fittings,
cabinetry, music and texture also a consideration.
Imaginative use of floor and wall finishes, colour and lighting will help to
produce a warm, friendly environment. However, all must conform to
infection control and other guidance, be seamless, easy to clean &
resistant to damage.
Some patients, could stay in the hospital for a number of months or years
and as such the environment of these areas should contrast significantly
from acute clinical environments. These wards must also comply with
health & safety and infection control but be firmly balanced with a sense of
homeliness.
All accommodation must conform to the requirements of the Disability
Discrimination Act 2005 including wheelchair access into rooms, provision
for those who have hearing or visual impairments and for obese patients.
Attention is drawn to the design guidance contained in the following
documents, which is not exhaustive:
14
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Way finding: effective way finding and signing systems – guidance
for healthcare facilities (NHS Estates, 2005)
Improving the Patient Experience (NHS Estates, 2003)
Internal Environment: Evaluation of the King’s Fund, Enhancing the
Healing Environment Programme (NHS Estates, 2004)
HTM 2045 Acoustics: Design Considerations
Delivering Quality & Value, Institute for Modernisation &
Improvement
Lighting and colour for hospital design, Dalke et. Al. (NHS Estates,
2004)
The Art of Good Health: using visual arts in healthcare (NHS
Estates, 2002)
Environmental Strategy for the NHS, (NHS Estates, 2005)
The role of hospital design in the recruitment, retention and
performance of NHS nurses in England, CABE, July 2004
The Disability Discrimination Act 2005
Health & Safety at Work etc. Act 1974
COSHH regulations and recommendations
Scottish waste management regulations, 2005
Changing the culture (DHSSPS, 2006)
Ward Sister's charter (DHSSPS, 2006)
Protecting patients and staff (DHSSPS, 2005)
HAI-SCRIBE (Health Estates, 2006)
Royal College of Psychiatrists College Research Unit, Management
of imminent violence: clinical practice guidelines to support mental
health services, Occasional Paper OP41, London, 1998.
http://www.rcpsych.ac.uk/publications/guidelines/ index.htm
Scottish Health Planning Note 22
It is noted that all environmental and service requirements should
correspond to the standards described in the relevant Scottish health
Planning Notes and other technical guidance and the technical output
specification for this project.
15
Overview: Outpatient Accommodation
Outpatient accommodation within the North Ayrshire Community Hospital
facility has been developed as a series of self-contained areas that are as
described in the Schedule of Accommodation. These include a range of
support accommodation such as waiting and administrative areas as well
as clinical support spaces.
Recognising the overview of accommodation provided previously it is noted
that outpatient accommodation within the new build facility will primarily
support mental health, psychological and therapy-related interventions.
Rooms are included for group-type work as well as a number of specialised
areas to meet the needs of particular clinical groups, e.g. Child and
Adolescent Mental Health Services (CAMHS).
Regarding the latter group, it is important to reflect on all current regulations
regarding the management of children in hospitals and in particular the
need to identify dedicated facilities for children that prevent any mixing of
paediatric and adult services. It is envisaged that the scheduling of an
entire cluster for children’s outpatient services may make this particular
design challenge a little easier.
As in all clinical areas, consideration must be given to protecting the privacy
and dignity of patients. Sound attenuation measures to ensure speech
privacy in consult / exam, treatment, and other rooms where patients and
clinicians have private discussions should be provided.
The design also needs to take account of the need to create a pleasant
environment for the patients and staff by means of good design, locally
controllable lighting and access to natural light and views.
Attention is drawn to the specific design guidance contained in:
•
•
Outpatients Department (HBN 12, NHS Estates)
Royal College of Psychiatrist Guidelines on consulting rooms has
been considered (reference already provided)
16
Overview: In-patient Accommodation
As previously noted, the preferred configuration for the new facility is a
“cluster” model that sees wards and other clinical areas distributed around
shared/common areas that contain a range of supporting facilities/services
as identified in the massing diagram and schedule of accommodation.
Leading from the entrance areas to the wards there should be sufficiently
wide corridors to allow passage of varied numbers of staff, patients and
visitors this should also support separation of facilities management (FM),
visitor and patient routes.
This approach has a number of benefits:
•
•
•
•
It restricts the crossing of patient, visitor, staff and FM flows and the
associated risks
It improves security by restricting the public to parts of the building
and routes that are less sensitive.
It improves privacy and dignity for patients who are being transferred
to another ward/department, e.g. Diagnostics
Transport of goods and services to a staff controlled area which can
be well protected against physical damage
The inpatient wards at the new North Ayrshire Community Hospital –
although specific in function and elements of configuration - will, as far as
possible, comprise core generic elements in order that they may flex
optimally over time. This flexibility is required in order to respond to clinical
and demographic changes in the patient population without the need for
major re-configuration. One key manifestation of this flexibility will be a
design that allows individual ward boundaries to change in the future if
required.
It should be noted that different fittings will be required in different
wards/clinical areas and that individual clinical briefs (in Appendices)
outlining how different patient groups have significantly different
accommodation layout requirements. Notwithstanding this however a
number of generic components of the clinical ward model can be identified
including:
•
•
100% single rooms per ward - all with en-suite accommodation
The majority of single rooms at 15.5m2 (including associated
17
•
•
•
•
•
•
•
•
•
•
•
•
family/clinical support space)
Most ward areas having 1-2 rooms at a larger size (18m2) to provide
additional functionality and flexibility. These larger rooms should
normally be those located closest to observation areas and have
overhead hoists where specified.
All rooms should be planned with en-suite chamfered showers,
WC’s and Wash Hand Basins as per HBN 00-02 at 4.5m2.
All rooms should be capable of using the global footprint available to
support patient care as required both within the bedded and en-suite
areas, i.e. Rooms should be designed in a manner that allows the
en-suite and bedded component to at different times “borrow” space
from the other.
All rooms should optimise patient/staff observation and the volume
of natural light entering the entire ward whilst minimising travel
distances for staff and ensuring the maintenance of privacy and
dignity.
Ceiling mounted tracking hoists will be required in some rooms
although this will vary by clinical specialty and should be referenced
from the detailed element of the brief presented in the attached
appendices.
The rooms with tracking hoists should be located as close to key
observation areas as possible and should be considered to be those
rooms that will accommodate the patients who require the most care
intervention and the closest observation. These will normally include
the larger sized single rooms.
All tracking should be kept as straight as possible to minimise travel
distances and maintenance requirements.
Tracking should allow patients to be moved between bed, bed-side
chair, WC and shower without any requirement for manual handling
intervention.
IT is seen as fundamental to the efficient functioning of the new
facility and should be considered at every stage of the design
process. In particular the use of IT to reduce workload, repetition
and errors is key. Specifically, it should be assumed that the new
facility will be “paperless” and that consequently access to IT
systems will be required everywhere clinical staff interact with
patients. This will include at nursing stations, in offices, therapy
areas, consulting rooms, “touch-down” bases, clinics, hot desk
areas, etc.
Specifically, the IT network should include an infrastructure for basic
a range of wireless/PIR facilities for each ward supporting both IT
and patient safety such as falls reduction.
The move away from a single nursing station in many areas should
be supported by the provision of informal desk space throughout the
clinical area, e.g. “Touch down stations”. These areas may at
different times be used by all members of the multi-disciplinary team
and should support the requirements of immediate documentation
review/completion (ideally electronically and wireless) as well as
18
•
•
•
•
•
•
•
•
•
direct two-way observation.
Many staff within the new facility will be moving from multi-bed ward
areas with design and technology seen as crucial to supporting their
clinical observation of patients within single rooms.
Secure medicines lockers should be provided at each bedside for
the storage of patients’ own drugs and to facilitate patient selfadministration of medications. (POD)
Each room should have a coded safe with over-ride facility
Rooms where Patients reside for longer periods need sufficient
storage to accommodate more personal items and clothing
The majority of offices will not be within the new facility but will
instead be located within other parts of the retained estate. Key
clinical offices are however scheduled where required.
Public access to the wards should be controllable at all times with
e.g. proximity card access/video-entry phone.
A key feature of all wards is a “reception room” which it is envisaged
may at different times be used to support patients, relatives and
visiting staff as they enter/leave the clinical area. To this end, this
room may be required to perform different functions in each ward
area ranging from a traditional type “reception” to “air lock” type
room or interview/family meeting space.
Clean and dirty FM routes and patient / staff routes should be clearly
identified and should be kept separate as far as possible.
Although all beds will require bed head services that include nurse
call systems, agreed entertainment systems, etc, piped gases are
not a feature of any bedrooms within the facility.
•
In addition, attention is drawn to the design guidance contained in the
following documents:
•
•
•
•
•
SHPN 04, Inpatient Accommodation: Options for Choice (NHS
Estates)
HBN 04, Supplement 1, Isolation Facilities in acute settings (NHS
Estates, February 2005)
SHPN 08, Facilities For Rehabilitation Services
SHPN 35, Accommodation for People With A Mental Illness
SHPN 37, Facilities For Older People
Internal Ward Relationships
The Board recognises that the move from wards with multi-bed bays to
100% single rooms with en-suites will represent a significant change in
practice for both staff and patients, with a key element of the successful
design the ability to optimise the two-way visibility of staff and patients in
both rooms and social spaces.
19
Whilst, as noted previously, the use of technological ways of achieving this
should be explored, a number of design priorities should also be observed,
as should the general principles of “lean management” and “the productive
ward”. Specific key elements of internal ward relationships worthy of note
are:
Staff Bases
As noted previously, multiple staff bases are specified in some areas,
particularly for night time use (touch-down bases), with a key general
element of the design the requirement to observe as many patients as
possible from each base.
En-suites
The position of the en-suites should not compromise the observation of
bedrooms. Consideration, therefore, should be given to how good
observation levels can be achieved from corridors and staff bases. In this
context, the positioning of en-suites relative to beds is extremely important.
The preference of the clinical groups reviewing ward design is for
“interlocking” and/or “in-board” en-suites as it is believed that these deliver
the optimal combination of two-way observation, light ingress, travel
distances and economy of the footprint.
Corridor/Door/Lift and Communication Area Sizes and Design
It is essential that beds can be manoeuvred in and out of bedrooms and
clinical areas within wards as well as along corridors and out of the ward to
all clinical and supporting areas, e.g. adjacent wards, diagnostics, the bed
storage/repair area, etc. The maximum dimensions of beds (including
attachments where necessary, e.g. Drip stands, pumps, monitoring
equipment., traction, etc) should be taken into consideration in this regard.
Similarly, bed lifts (if provided) must be able to take a bed and attachments
along with up to 4 attendant personnel
Utility Rooms
The position of clean and dirty utility room(s) as well as other “common”
areas must ensure that distances from bedrooms and other clinical areas
are not excessive.
Socialisation Space
Socialisation space is a key component of all ward areas as in all wards
patients/service users will spend the vast majority of the day period out with
their bedrooms although it is noted that the preferred layout/configuration of
20
this space varies considerably by clinical area.
To ensure future medium/long term flexibility it is important that the design
of all clinical areas facilitates a model whereby socialisation space can be
used flexibly to meet the specific requirements of different patient groups
this will include quiet and reflective time, entertainment and therapeutic
activity. This requires to be balanced by maintaining an optimal relationship
with bedroom and support/cluster accommodation.
Overview: External Areas
Many of the individual service templates attached focus on the essential
requirement for exterior spaces and private gardens and terraces including
on any upper floors as well as the more public spaces for walking or cycling
Where provided, these areas should also form part of the overall
therapeutic environment and be subject to the same considerations and
principles identified throughout this document.
Hours of Service & Work Patterns
Unless stated explicitly in detailed area briefs it should be assumed that:
•
•
•
All wards will operate 24 hours/day, 365 days/year
Outpatient areas will normally operate from 8-5 Monday to Friday
and evenings. There may in the future be availability to provide
weekend and out of hours appointments/sessions
Administration areas will primarily operate between 8-5 Monday to
Friday, although meeting rooms may be required to support
evening/weekend events
As administrative areas are unlikely to be staffed out with office hours the
implications of this should also be considered within the design. Specifically
this should allow for these areas to be locked when un-staffed with a
separate provision for out of hours visitors to make contact with
ward/clinical staff before being allowed access to clinical areas.
21
Pathway & Patient Flows
Patients may be admitted to wards from a number of areas including:
•
•
•
•
Home
GP surgeries/ Health Centres
Other clinical facilities such as community based clinics, District
General hospitals or other hospitals
Outpatient departments
These admissions may be either elective (planned) or unscheduled (un
planned).
Separating scheduled care from unscheduled care is an important element
in planning for the optimal utilisation of all resources and will be key to the
overall model employed in the new hospital.
Scheduled patients will normally be admitted directly to a ward which they
may access either via the clinical and consulting area, main entrance or Inpatient (Ambulance) entrance should they be arriving by ambulance,
hospital car or require to be dropped off close to an entrance for mobility or
privacy reasons.
It is noted that the ambulance entrance must also facilitate discrete access
to both IPCU and the Forensic Rehabilitation/low secure ward, either
directly or via the adjacent support cluster, in order to admit patients to
these areas under escort with the minimal of mixing with other patients and
to facilitate privacy and dignity. (This may also be achieved through a direct
entrance to these facilities at an entrance where vehicles can be parked
safely if the design allows)
Outpatients will normally access clinical areas via the scheduled main
entrance into the new building or via the existing entrance in the Horseshoe
building for general outpatients, X-ray, etc. The fact that there will be two
discrete outpatient areas within the facility may lead to confusion,
emphasising the requirement for clear operational processes, an effective
way-finding strategy and a design that optimally locates the new OP
department as close to the existing area as possible. It is noted that whilst
this would be a desirable element of the design there is no clinical reason
to link both outpatient areas as they will be managing completely separate
patient groups.
22
Once in the facility in-patients and out-patients may require to access, visit
or go to a range of other areas to which clearly identified routes should be
available including:
•
•
•
•
•
•
c.
Diagnostics – within the existing Horseshoe
Therapy, in any one of a number of identified therapy areas in
clusters
Outpatients – even if they are an in-patient (When clinically
appropriate)
ECT/Minor Surgery area – primarily from elderly and adult mental
health wards or from the inpatient areas elsewhere in South or East
Ayrshire. Rarely people may attend as an out patient.
Wards – primarily from entrance area
Service Continuity
It is essential that, during construction, all services are maintained on the
hospital site within the existing operational buildings. This will present
significant challenges in terms of care delivery, goods in and out, utility
connections, etc.
Whilst many of these issues will be progressed through close working with
technical staff and the established service continuity group, etc, it is
important to recognise that Ayrshire Central Hospital is, and will remain
throughout the build process a busy, functional clinical facility. The safety of
everyone visiting or resident within the site must remain paramount at all
times with regards to both the direct and indirect effects of the development
process.
Specifically it is noted that careful planning will be required around the
range of services supported by pavilions 1-3 as it is anticipated that these
will be retained while construction work take place and 10 &11 at the other
end of the site.
•
•
•
In-patient accommodation will move to the new facility
Mental health/psychology/CAMHS/Addictions related outpatient
activity will move to the new build “consultation and interventional
area”
Administrative accommodation will move to retained accommodation
within the Horseshoe
23
It is envisaged that significant car parking will be required to support the
new facility both in its final format and throughout the build/development
process and that this should be agreed in liaison with the North Ayrshire
Council Local Authority and in conjunction with the development of a Green
Travel Plan at a later stage.
3. Schedule of Accommodation
The current Schedule of Accommodation is attached as Appendix C.
All of the required rooms/spaces are identified within the attached Schedule
of Accommodation with room details/specifications to be in line with the
identified guidance.
It is important to note that:
•
•
•
•
Every opportunity to appropriately rationalise scheduled areas
through design should be identified
Accommodation should be as flexible as possible
Links to existing estate should be clearly identified
A key design challenge will be making the whole facility (new build
and existing estate) operate as one seamless clinical unit
•
To support an optimally efficient design, an adjacency matrix is presented
as Appendix D, whilst Appendix E outlines those areas that must be located
on the ground floor and those that could be located on upper floors.
Appendices F to T present a more detailed operational overview of
individual components which have been fundamental to the development of
the Schedule of Accommodation, massing diagram and adjacency matrix.
24
Appendices
A
Visual Clinical Specification
B
New build Adjacency Diagram
C
Schedule of Accommodation
D
Adjacency Matrix
E
Ground/Upper Floor Considerations
F
Central (Walk-in entrance)
G
“Ambulance” entrance
H
Consultation & Interventional Area
I
Multi-function ECT/Minor Surgery/Therapy Area
J
Pharmacy/Dispensary
K
Tribunal/Meeting Area
L
Acute Mental Health Wards
M
Intensive Psychiatric Care Unit (IPCU)
O
Addictions Ward
P
Rehabilitation unit (Adult Mental Health)
Q
Elderly Mental Health Wards
R
Rehabilitation Ward (General Health)
S
Long Term Care (Continuing Care)
T
Support Clusters
25
Appendix A – Visual Clinical Specification
OUTSIDE SPACE
26
• Outside space should be accessible from
individual wards. Should include social and
recreation areas and green space.
27
• Outside space may be used to increase the
feeling of light and space indoors by, for
example , the use of large windows.
• Outside space should be accessible to people
with limited mobility.
28
Should not be overlooked, give the impression of
being confined or cramped.
29
INTERNAL SPACES
30
• Public Spaces should
maximise the use of
natural light.
• Seating should be
provided in corridors and
public spaces.
31
• Reception Areas should be
comfortable, welcoming
and attractive.
32
• Long dark corridors
and unwelcoming
reception areas
must be avoided.
33
• Day Areas, including
open-plan and smaller
sitting areas retain
impression of light and
space.
34
Appendix B - New Build Adjacency Diagram
35
Appendix C – Schedule of Accommodation
BUCHAN
ASSOCIATES
TD
Schedule of Accomodation
MASTER SHEET
Accommodation
Type
Central (Walk-in) Entrance
Consultation & Inverventional Area
Ambulance Entrance
20 Bed AMH Wards (MH)
30 Bed Rehab' Unit (MH)
8 Bed Forensic Rehab' Unit (MH)
8 Bed IPCU (MH)
10 Bed Addictions Ward (MH)
15 Bed Elderly Wards (MH)
ECT/AHP/Minor Surgery Suite
Support Cluster 1 (AMH)
Support Cluster 2 (Rehab)
Support Cluster 3 (Elderly)
30 Bed Elderly Rehab Ward
30 Bed Long Term Care Ward
Pharmacy
Tribunal & Meeting Area
Total
Admin
OP
Admin/Circ
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical/Admin
Clinical/Admin
Clinical/Admin
Clinical
Clinical
Admin/Clin
Admin
ADD PLANT
ADD COMMUNICATIONS
TOTAL
Net m2
2
m
Gross
2
m
517
521.5
55.25
722.0
744.7
77.2
3027.7
1526.3
677.6
657.7
676.8
1725.9
255.9
313.8
163.5
282.8
1438.7
1438.7
154.9
154.0
14038.0
1045.75
464.25
444.25
463.75
183.25
219.75
112
193.75
985.75
985.75
115.25
110.25
Comments
3 x 20 bed wards
1 x 30 bed unit
1 x 8 bed ward
1 x 8 bed ward
1 x 10 bed ward
2 x 15 bed wards
737.0
1825.0
16600.0
Approved on behalf of NHS Ayrshire & Arran
NAME
SIGNATURE
DATE
Version: OBC "As drawn" 1
N Sutherland
36
Appendix D – Adjacencies Matrix
North Ayrshire Community Hospital Adjacencies Matrix
E
D D
D E
D
D
D D
D D D
D D
D D D D D D
-
D
D
Staff changing (In Horseshoe)
Spiritual Care Area
Existing general outpatients (In Horseshoe)
D
Tribunal Suite/Meeting Area
Dining Room (Existing Facility)
D D
D
D D
E
D
D
D D D D
D D D D
D
D D D
Rehabilitation Unit (30 bed, mental health)
Rehabilitation Ward (30 bed frail elderly ward)
D
E E
Pharmacy
Public Transport Pick Up/Drop Off
D
IPCU
Long Term Care Ward (30 bed frail elderly
D
D
D
E -
Elderly Mental Health Wards
Forensic Rehab' (8 bed, mental health)
D
D
E D D
D -
Consultation & Interventional Area
ECT/Minor Surgery/Therapy Area
E
D D
D D
E
D
D
E
D
D D
D
D
D
D
D
D
"Ambulance" Entrance
Central (Walk-in) Entrance
E
D
D
D
D
Acute Mental Health (AMH) Wards
Addictions Ward
Acute Mental Health (AMH) Wards
Addictions Ward
"Ambulance" Entrance
Central (Walk-in) Entrance
Consultation & Interventional Area
ECT/Minor Surgery/Therapy Area
Elderly Mental Health Wards
Forensic Rehab' (8 bed, mental health)
IPCU
Long Term Care Ward (30 bed frail elderly ward)
Pharmacy
Public Transport Pick Up/Drop Off
Rehabilitation Unit (30 bed, mental health)
Rehabilitation Ward (30 bed frail elderly ward)
Tribunal Suite/Meeting Area
Dining Room (Existing Facility)
Staff changing (In Horseshoe)
Spiritual Care Area
Existing general outpatients (In Horseshoe)
Notes:
E = "Essential" adjacency. There is a definite clinical/operational rationale for these areas to be easily accessible from/between each other that must be a feature of the design
D = "Desirable" adjacency. Although not essential, there is a clear advantage associated with these areas being closely aligned if this can be achieved through the design
37
Appendix E – Ground/Upper Floor considerations
Services/ wards/ departments
that definitely could be provided
on the Upper floor
Central (walk-in) Entrance: Café
Area/Coffee Shop/Retail
Services/ wards/ departments that could be
provided on the Upper floor but would be a
managed challenge/risk
Support Cluster 1 Adult Mental Health
Central (walk-in) Entrance:
Support facilities: sanitary
Support Cluster 2
Central (walk-in) Entrance:
Spiritual Care Area
Support Cluster 3 Elderly
Managed challenge/Risk if providing service on
the Upper floor
This Support Cluster must be easily accessible
to the wards it is supporting – Adult Acute
Mental Health, IPCU & Addictions
This Support Cluster must be easily accessible
to the wards it is supporting – Forensic
rehabilitation/Low Secure, Rehabilitation unit
and Addictions.
This Support Cluster must be easily accessible
to the wards it is supporting – Elderly Mental
Health, Frail Elderly Long Term Care and Frail
Elderly Rehabilitation Ward.
Central (walk-in) Entrance:
Hospital Admin/Support
Central (walk-in) Entrance:
Mental Health Operational
Management Team
Mental Health 30 bedded (3x10)
Rehabilitation Unit
Consultation & Intervention Area
Mental Health 15 Bed Ward Addictions
Services/ wards/ departments that
definitely could not be provided
on the Upper floor
Central (walk-in) Entrance: Main
Entrance
Ambulance Entrance
Mental Health Acute 20 Bed
Wards x 3
Mental Health 15 Bed x 2 Wards –
Elderly
Intensive Psychiatric Care Unit
(IPCU)
Forensic Rehabilitation/Low
Secure
Rehabilitation Wards (Frail
Elderly)
Frail Elderly Long Term Care Wards
Require easy access to safe outdoor space on
the same level and access to outdoor space on
ground level
Frail Elderly Rehabilitation inpatient Accommodation
ECT Suite/AHP Area/Minor
Procedures Area
Pharmacy/Dispensary
Tribunal & Meeting Area
38
Appendix F – Central (Walk-in) Entrance
Introduction and outline of services
Departmental Function
Our central walk-in entrance, reception and ancillary will provide:
•
•
•
•
•
Main Entrance with reception area, records area, waiting area,
porters and security offices;
Café area/coffee shop/retail;
Support facilities: sanitary;
Spiritual care area; and
Hospital admin/support including a cashiers office Mental Health
Operational Management Team offices.
Scope of Service/Specialist Services Provided
The accommodation is scheduled in common area and is described in the
section entitled Main Entrance, Reception and Ancillary Accommodation in
the Schedule of Accommodation.
39
Model of Care
Descriptive Overview
The purpose of the Main Entrance, Reception and Ancillary Accommodation
will be to provide an arrival point for patients (some arranged admissions
transported by family; outpatients with or without carers; day patients with or
without carers), visitors (to wards or attending meetings), staff and
occasionally, goods. It will be an initial point of contact for individuals with
enquiries.
Reception service may have to help individuals with particular problems, for
example, mobility - finding a wheelchair, restlessness/anxiety. Help or
escorting to a destination may be required, for example, cognitively impaired
or sensory impaired patients/visitors. Staff in this area will need to have a
detailed knowledge of the workings of the entire hospital in terms of who,
where, how to, etc., failing that, speedy access to someone who does.
The Main Entrance, Reception and Ancillary Accommodation will be
provided for 365 days, 7 days per week. The emphasis will be on being an
initial point of contact for individuals arriving at the hospital and helping
people to be in the right place at the right time.
A front desk reception to receive patients, relatives and NHS staff will be
operational during Monday-Friday 9-5pm. “Welcomers” may man this desk.
This area will allow one member of staff to greet the above people with a
computer to access information. Directly behind this reception desk will be a
room to house five staff and space for medical records for the hospital.
Three of the staff will carry out the medial records function and two staff will
complete the staff personnel function, recruitment, engagement and
termination of staff. These staff would also manage the consultation and
interventional area and support the reception area. The reception with
associated medical records and admin function area would require to be on
the ground floor. Healthy choice vending machines will be available at the
main entrance.
The main entrance will require to be accessible 365 days, 7 days per week,
24 hours a day. To complement this accessibility as very few evening and
overnight attendances are expected a form of ‘lock down’ permitted
entrance is desirable rather than full open access at very low usage and low
staffing times.
The café area /retail area will ideally open seven days a week and into the
evening visiting. This area should be able to be secured when not in use.
40
Within the Management Team’s area a room will be required to
accommodate three people, to provide secretarial support to the Service
Manager , the Senior Nurse, the Operations Co-ordinator and a secretary to
support the procurement service and the Clinical Nurse Manager. This office
could be placed on the upper floor. An office for the Psychiatry consultants
who will be permanently based here (up to two WTE) could be located either
with the Management Team or in an office in cluster for rehab. Ideally
located with medical secretaries.
The spiritual care area will require to be accessible 365 days, 7 days per
week, 24 hours a day and should be in a quiet area of the main entrance.
The main entrance area should:
•
•
•
•
•
•
•
•
•
•
•
•
Be well signposted and easy to find, adequately sized, and offer level
and unobstructed entry;
Be well lit, staff and patient friendly and signed in such a way that
patients and their escorts can find their way immediately. Ideally,
patients accessing the main entrance should not have to pass the
ambulances offload area;
Create a calm and restful atmosphere and an environment which is
non-threatening;
Have an entrance with a canopy so that patients are offered
protection from adverse weather conditions as they transfer from
ambulances, taxis or private transport. The canopy should also be
large enough to provide the same protection to cars unloading
passengers/patients. The area should be well lit;
A wheelchair bay should be provided adjacent to the main patient
entrance lobby for immediate use;
The provision of a drop-off zone close to this entrance for taxis or
cars dropping off patients, which will include elderly or infirm;
The provision of waste bins and salt bins should also be provided
The entrance should be bright and easily identifiable from entrance
roads, with good signage (see ‘Wayfinding’ NHSScotland);
The entrance must provide adequate access for public transport
vehicles, in particular for buses to manoeuvre in and out easily, taking
account the length of buses;
This entrance should have a suitable draught lobby, with two sets of
automatic sliding doors adequately positioned far enough apart to
ensure heat is retained within the building and that patients and staff
are not subjected to draughts. It should not be possible to open both
sets of doors at the same time unless in an emergency.
The main patient entrance lobby is often a busy place. It will need to
accommodate patients with a variety of conditions, including those
using wheelchairs, those on foot but using walking aids, and those on
foot but supported by escorts.
It is essential that the lobby is large enough to permit easy movement
of this traffic, and it should have a floor covering that will trap dirt
carried by footwear or on wheels, and which can be easily cleaned. If
41
•
•
•
•
•
•
•
•
•
•
•
•
metal strips are used then designers should note that these can have
an adverse effect on some people’s vision. See also ‘Welcoming
entrances and reception areas’ (NHS Estates, 2004);
Afford no undue separation of staff from patients;
Be attractive, uplifting and interesting in terms of décor, fabric,
furnishings and interior and exterior design, as well as the use of
natural materials, colour and textures;
Create a feeling of well ventilated space, maximising the use of
natural light and minimising the reliance on artificial light;
Be sensitive to the needs of physically disabled patients, visitors and
staff;
Consider space and environment and recognise that this will be
important from both the external and internal perspective;
Be imaginative and creative use of space will be vital, for example,
the avoidance of long corridors and the creation of attractive easily
maintained/accessed landscaped gardens;
It is essential for the service to be flexible to the changing needs of
individuals and groups e.g. changes in conditions, gender, numbers,
cultural needs etc.
The physical environment will require to be responsive to such
changes in demand;
All therapeutic rooms should be designed to enable speech privacy;
and
Adequate provision of telephone access and IT infrastructure will be
critical to effective communication, education and provision of
evidence-based practice.
This area has been described further in the exemplar design.
Role and Function
•
•
•
•
•
•
The main function of the reception area is to meet and greet patients
and direct patients and relatives. If a receptionist is concerned about
a patient’s condition, they should be able to summon help from
clinical staff. “Welcomers” could provide this service which would
provide a dual role, engaging with the community and encouraging
volunteering and would also provide a cost effective service;
Requires a hearing loop system at the main reception;
There will be a focus on clinical and environmental safety and
security for the patient, general public and staff within the service;
The environment requires to lend itself to obtrusive and unobtrusive
observation and in-keeping with Millan Principles;
The environment must be pleasant, safe and the general ambience
should promote mental and physical health well being; and
It will continue to work closely and link with the community
infrastructure.
•
Bed complement
•
No beds will be provided in this area
42
•
Planned patient activity
•
•
Not applicable
General principles of operation
•
Not applicable
Design Synopsis
In addition to the core design synopsis/critical features, unique features to
this environment will be:
•
•
•
•
•
•
•
•
•
•
•
•
Welcoming & homely;
Well ventilated and spacious;
Maximum use of natural and artificial light;
Maximum use of natural and artificial ventilation;
Discreet hotel and storage services;
All areas should be spacious, preventing those using our service
feeling enclosed;
The reception area should be located in an open space directly inside
the entrance. The position of the reception area should allow
reception staff to see all patients and escorts entering the department
and have vision to the main waiting area;
The design of the reception desk should be of a high quality and
allow access for people with disabilities. It is appropriate to make the
reception desk as friendly as possible; the inclusion of a hearing loop
is a requirement. The inclusion of children’s decor/mosaics should be
considered. ‘Friendly healthcare environments for children and
young people’ (NHS Estates, 2004) gives greater detail on designing
a child-friendly environment. Care must always be taken to ensure
that designs are suitable for all users; children, people with disabilities
and disturbed patients. (www.fairforalldisability.org);
The reception desk is the focal point of the waiting area. It requires to
oversee the waiting area but care must be taken to ensure that those
in the waiting area cannot overhear any discussions at reception.
Computer facilities will be required for reception staff;
The administration office should be provided behind the reception
desk where access to photocopying, faxing, printing equipment and
the disposal of confidential waste paper etc. will be required; and
Security of the reception area should include the use of personal
alarm transmitters.
The waiting area will be required to accommodate some patients
during very busy periods and for family and friends who accompany
the patient to hospital. The general circulation area is the least easily
43
defined, as it has to provide a number of varying environments. From
a design professional’s viewpoint these are:
•
o a waiting area for patients prior to their assessment;
o a sitting area for friends and family, as some may elect to stay
in the waiting area;
o a designated, secure play and waiting area for children,
possibly out of sight from the main adult waiting area but
supervised by the staff at reception; and
o an area for enquiries, information, and providing
literature/notices of primary healthcare and local facilities.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
The design of the waiting area and all sub-waiting areas will include:
circulation space for wheelchair users and pushchairs;
space around seating for parking pushchairs and wheelchairs without
impeding circulation areas;
access to public or free phones for contacting friends, relatives, work
etc;
access to a text phone for those unable to use a public phone or a
sign indicating that staff can make one available at reception or
somewhere suitable;
if TVs are provided, they should include text and locations must not
interfere with any hearing loop systems;
information boards (a sufficient number must be provided to prevent
notices being stuck to walls, doors etc.);
access to drinking water dispensers and possibly vending machines
for healthy snacks, etc as some people arrive hungry or may have to
wait for return transport.;
the use of natural lighting where possible, although thought should be
given to shade control;
appropriate heating and ventilation;
good, clear signage at appropriate height levels with maximum use of
symbols or pictorial messages to assist those with poor reading or
language difficulties in locating all services; and
The seating layout should be considered carefully to prevent
confrontational situations, for example, avoid seats directly opposite
each other.
•
44
Corridors: Required features
•
•
•
•
Corridor area should be kept to a minimum;
Corridors should have no blind spots and allow maximum observation;
Where corridors are not just to get from A to B they could have the opportunity
for informal social contact, non institutional and natural light; and
Corridors should provide seated areas for quiet contemplation and where
possible views of shrubbery and gardens. Ward areas especially bedrooms
and garden areas should not directly overlooked by any corridor.
Mixed gender requirements
•
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
•
The design of the unit must comply with current legislation
Privacy and dignity requirements
•
The design of the unit must comply with current legislation
Required adjacencies
External
•
•
The Main Entrance, Reception and Ancillary Accommodation should
have access to all ward areas without going outside; and
Access to outpatient clinics in the consultation and intervention area
and access to the ECT/minor surgery/therapy area without going
outside.
•
Internal
•
•
•
•
The café/area/coffee shop/retail should be located near the entrance;
The spiritual care area should be in a quiet area located near the
entrance;
The hospital admin/support should be located behind the
Reception/volunteer desk and in the ground floor;
The Mental Health Operational Management Team offices should be
located near to clinical services and could be located on the first floor;
and
•
45
Storage facilities
The following storage facilities are required for:
•
•
•
•
Porter’s;
Security;
Community/Multipurpose/health
store); and
Wheelchairs.
Education
Room
(including
HE
Anticipated developments
•
•
•
During the lifespan of the building a flexible approach to design will
be required which takes into account changing models in delivery of
care;
The building should be able to meet the needs of future Information
Technology developments; and
The building should be flexible in design to meet the challenges of an
ever changing and improving Health Service.
46
Client Group Characteristics
Age and Gender
•
•
All ages will access the Main Entrance
Admission Rates
•
The main entrance should be open 365 days a year, 24 hours a day
but will be securely closed after visiting (around 10pm) and reopened
in the morning Monday - Sundayto maintain security and safety for
patients and staff.
Diagnoses
•
Patients admitted to the facility will have a varying range of mental
health problems/illness and may some will experience issues re
drug/alcohol misuse. They may be elderly and will be frail or possibly
confused. Elderly patients are likely to have elderly relatives who may
also be physically or mentally frail.
•
Anticipated illness-related behaviours
•
The café and other entrance areas are likely to be a popular place for
patients and visitors alike. Space and choice of seating areas will
assist.
Anticipated clinical risks
Clients who are admitted to the facility may be at risk from the following:
•
•
•
•
•
•
•
Harm to others;
Poor motivation;
Self neglect;
Suicidal intention;
Isolation in a community environment (social breakdown); and
Institutionalisation.
Physical dependency and immobility
47
Patient dependency characteristics
Therapeutic Intent
Principal aims of clinical care
•
•
Not applicable
Therapies
•
•
Not applicable
Therapeutic facilities required
•
•
Not applicable
Planned clinical meetings
•
No clinical meetings will take place in this area
Other Meetings
•
•
Not applicable
48
Clinical risk management principles
•
•
Not applicable
Operational Procedures
Working day plans
•
•
The main entrance will be open 365 days per year and 24 hours per
day, but will closed after visiting Monday-Sunday. The café area/
coffee shop and retail will be closed after visiting hours.
Security staff will be based in the main entrance 365days/24hrs,
however the desk will not always be manned as security staff will
require to undertake rounds throughout the site but will always be
available on pager and 2way radio system.
Staffing arrangements and shift patterns
•
The main entrance will be staffed 365 days per year and 24 hours per
day.
•
Admission procedures
•
•
Not applicable
Record-keeping storage
•
•
•
•
In administrative areas, all clinical case records require to be stored
within a lockable cabinet within a lockable room;
Items of secure stationery require to be stored within a lockable
cabinet;
The administration office area will be located behind the reception
desk with a medical records area adjacent; and
The medical records area within the central walk in entrance will
require to be extremely secure with access only by Administration
and occasionally clinical in and out with office hours. This area must
have appropriate medical records storage.
•
Visiting arrangements
•
Visitor will enter via this area and there will be a varied but planned
visiting time schedule. It is unlikely that visitors for the 206 patients
would require to arrive at the one time although there will be peak
49
times.
•
Mealtimes/dining arrangements
•
•
•
Facilities must promote the ambiance of the meal experience; and
Cafe/coffee shop will be accessed by patients, visitors and staff.
Laundry facilities and linen management
•
•
Not required in this area
Functional content
Number of Inpatient Beds/Treatment Spaces
•
There will be no inpatient beds/treatment spaces in this area.
Investigative/Diagnostic/Treatment Capacity:
•
•
Not applicable
Outpatient Service (Number of Sessions and
specialist functions):
•
•
Not applicable
Specialist Technical Infrastructure Requirements
•
•
•
•
•
•
•
•
•
•
Personal alarms;
The reception area should be fitted with a discreet panic alarm
system linked to security;
Wall mounted alarms;
Emergency Response Team (2222);
Telephones for internal and external communications;
Mobile phones for escort duties; and
Emergency Response Pack.
Secure Entry System - Security/Portering staff will be based in the
main entrance to answer any queries
Access to E-health and other IT systems from staffed areas.
Announcements and health messages - what’s on type visual
50
announcements may be provided by a technology based solution
•
Projected Future Activity
•
Not applicable
Key Relationships with Other Departments
•
•
•
•
•
•
•
Activities – retail and coffee shop (café area/coffee shop will be
manned by either the Hospital Volunteers who will report to the
manager responsible for volunteers throughout NHS Ayrshire & Arran
or via directly provided services);
Discreet Ambulance or Clinical taxis arrivals ;
Chaplaincy;
Internal support services – hotel services, portering, administration,
IT, communications, finance, estates;
Pharmacy;
Service user groups/carer groups; and
Voluntary sector see comment above re. hospital volunteers and
other volunteer opportunities.
•
Future Service Delivery Risks
•
•
•
•
Ageing population – more elderly patients and visitors and carers;
Demographic changes;
Activity levels will vary but predicted to be consistently high and
Longer term future service demand is uncertain. This new provision
needs to reflect change in trends and be adaptable to future need.
51
Appendix G – “Ambulance” Entrance
Introduction and outline of services
Departmental Function
Our Ambulance entrance will provide entrance, minimal waiting space
a bed equipment store area
Scope of Service/Specialist Services Provided
The accommodation is described in the section entitled ambulance entrance
in the Schedule of Accommodation.
Model of Care
Descriptive Overview
The purpose of the ambulance entrance is to provide a safe and discrete
entrance to the unit.
All ambulance arrivals will be planned, the ambulance entrance will be
accessible for 365 days, 7 days per week, 24 hours per day. A secure entry
system will be operational with a buzzer ring to various named wards and to
Porter. Visual identification of arrivals would provide an additional security
feature especially in the Out of Hours periods.
The following will be crucial design considerations:
•
•
•
•
•
Create a calm and restful atmosphere and an environment which is
non-threatening;
Should be able to accommodate patients subject to all levels of
security;
Be attractive, uplifting and interesting in terms of décor, fabric,
furnishings and interior and exterior design, as well as the use of
natural materials, colour and textures;
Create a feeling of well ventilated space, maximising the use of
natural light and minimising the reliance on artificial light;
Area should be free from obstructions and should allow sufficient
space to accommodate the need for immediate physical
interventions;
52
•
•
•
•
Be sensitive to the needs of physically disabled patients, visitors and
staff; and
Adequate provision of telephone access and access to immediate
staff or emergency (2222) assistance.
Easy and secure transfer of patients to the IPCU
Role and Function
The purpose of the ambulance entrance is to provide a safe and essentially,
discrete and secure means of entrance to the hospital 24 hours a day 365
days a year.
Bed complement
•
No beds will be provided in this area
Planned patient activity
The ambulance entrance will be used for planned in patient admissions and
transfers from a range of sources described earlier.
Activity will be intermittent and may occur at anytime day or night. Doorways
should be wide enough to allow a minimum of three persons abreast to
enter. As with all entrances it should be able to accommodate the ambulant,
non-ambulant and persons with a disability.
Within this ambulance entrance there will be a bed/equipment store . a
seated area and space for wheelchairs
General principles of operation
•
The area should be capable of being secured at all times and will by
access in a planned way with authorised access system.
Design Synopsis
In addition to the core design synopsis/critical features, unique features to
this environment will be:
•
•
•
•
Welcoming;
Well ventilated and spacious;
Doors, locks and windows should be of a design which is antibarricade and enables access by staff in an emergency;
Maximum use of natural and artificial light;
53
•
•
•
•
•
Maximum use of natural and artificial ventilation;
Discreet hotel and storage services;
Ligature points should be eliminated
The Reception Area should have a panic alarm system for staff; and
All areas should be spacious, preventing those using our service
feeling enclosed.
•
Corridors: Required features
•
•
Corridor area should be kept to a minimum; and
Corridors should have no blind spots and allow maximum
observation.
Mixed gender requirements
•
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
•
The design of the unit must comply with current legislation
Privacy and dignity requirements
•
The design of the unit must comply with current legislation
54
Required adjacencies
External
•
The ambulance entrance should be covered / partially enclosed and
centrally located to allow easy internal access to all wards especially
IPCU
Internal
•
The bed and equipment store should be located in a secure area
accessible to the wards and in the utility area of the hospital close to
the loading bay, a foul drain will be required; and
Storage facilities
The following storage facilities are required for:
•
Bed/equipment store/test area
Anticipated developments
•
•
•
During the lifespan of the building a flexible approach to design will
be required which takes into account changing models in delivery of
care;
The building should be able to meet the needs of future Information
Technology developments; and
The building should be flexible in design to meet the challenges of an
ever changing and improving Health Service.
55
Client Group Characteristics
Age and Gender
•
•
All ages and gender could access the ambulance entrance
Admission Rates
•
The ambulance entrance will be accessible for 365 days, 7 days per
week, 24 hours per day, however is designed to be used as a
discreet entrance
•
Diagnoses
•
•
Patients admitted through this entrance will have a varying range of
mental health problems/illness.
Patients may be transferred by Ambulance from the General
Hospitals to the elderly mental health wards, rehab ward and long
term (continuing care) wards and may have varying degrees of
mobility and require wheelchair or trolley.
•
Anticipated illness-related behaviours
•
•
•
•
•
•
•
•
•
Aggressive behaviour (verbal and physical);
Aimless or ritualistic behaviours;
Disinhibited behaviours;
Lack of personal risk awareness;
Suicide risk;
Unpredictable and impulsive behaviours;
Primary and Secondary physical disabilities/illnesses; and
Fear and apprehension.
Confusion or poor mobility
Anticipated clinical risks
•
•
•
•
•
Clients who are admitted to the facility may be at risk from the
following:
Deliberate self harm;
Harm to others;
Poor motivation;
Self neglect;
56
•
•
•
•
Suicidal intention;
Isolation in a community environment (social breakdown); and
Institutionalisation
Risk of falls
Patient dependency characteristics
Therapeutic Intent
Principal aims of clinical care
•
Not applicable
Therapies
•
Not applicable
Therapeutic facilities required
•
Not applicable
Planned clinical meetings
•
No clinical meetings will take place in this area
Other Meetings
•
•
Not applicable
Clinical risk management principles
•
Risk management is important. Risk assessment should occur prior
to arrival as part of the planned admission or transfer process and will
be led by he clinical team from the receiving ward.
Operational Procedures
Working day plans
•
The ambulance entrance will be accessible 365 days per year and 24
hours per day, with secure entry
57
Staffing arrangements and shift patterns
•
The bed equipment store area will be operational during 9-5pm
Monday to Friday and may be required for storage of broken beds at
all times.
•
Admission procedures
•
•
Not applicable
Record-keeping storage
•
The Support Services Facilities Manager will be responsible for the
admin function in relation to bed storage area.
Visiting arrangements
•
•
Not applicable
Mealtimes/dining arrangements
•
•
Not applicable
Laundry facilities and linen management
•
•
Soiled linen (for example, disposable cloths and protective clothing)
will be collected and stored in utility rooms in the hospital prior to
transfer to the main soiled linen store; and
Clean linen will be stored in cupboards/trolleys.
58
Functional content
Number of Inpatient Beds/Treatment Spaces
•
There will be no inpatient beds/treatment spaces in this area.
Investigative/Diagnostic/Treatment Capacity:
•
Not applicable
Outpatient Service (Number of Sessions and
specialist functions):
•
•
Not applicable
Specialist Technical Infrastructure Requirements
•
•
•
•
Personal alarm system and or Wall mounted alarms;
Slow Door Systems (commended by MWC);
Secure Entry System out of hours, proposed multi-way system buzzer
ring to acute The security buzzer could be fitted with either buzzer or
discrete flashing light at the entrance to the wards. When the
operational policies are prepared this task could be assigned to
security staff; and
Telephones for internal and external communications.
Projected Future Activity
•
Not applicable
59
Key Relationships with Other Departments
•
•
•
Ambulance
Chaplaincy
Future Service Delivery Risks
•
It should be noted that patients may show signs of changes in
diagnostic pattern within admission
60
Appendix H – Consultation & Interventional
(Outpatients) Area
Introduction and outline of services
Departmental Function
Our consultation and interventional area will provide defined areas:
•
•
•
•
Main consultation and intervention reception/support area with
records area
Supporting two sub outpatient areas for adults
Outpatient clinic area (Child & Adolescent services) with reception
Consultation and interventional Area for adults x 2
The consultation and interventional area will be the main area for mental
health outpatient activity. This area will have two clinic areas which will be
accessed primarily by addiction services, learning disabilities, elderly,
forensic, community mental health teams, primary care mental health teams
eating disorders, forensic and the Clinical Psychology and Neuropsychology
service. The consulting and therapy space will be booked in advance.
Addiction services will utilise the adult clinic area for outpatient appointments
for new and return patients. Some patients attending will use the
specimen/WC room for drug screen analysis.
It is also envisaged that Addiction services will use this area for evening and
weekend work and would require appropriate security measures to ensure
staff safety, for instance, secure entry.
Learning Disability Services will utilise the adult clinic area for new and
return patients on single/multidisciplinary process initially on a Monday –
Friday 9-5 basis. Patients may present with multiple physically disabilities.
Patients may have to travel considerable distances and may require
specialised transport. It is therefore imperative that consideration is given
to toilet changing facilities, which can accommodate their needs and also
refreshment facilities for them and their escorts.
Mental Health Elderly services will utilise the adult clinic area rooms for new
and return patients Monday to Friday preferably after 11am to accommodate
the client group. Patients may have difficulty in travelling distances and this
should be taken into account in the location of this facility.
61
Primary Care Mental Health Teams will operate Monday to Friday, however
their may be a requirement to offer evening sessions to this client group.
Eating disorders and forensic outpatients will use a range of clinics MondayFriday with access required to the seminar room for group work and
consulting space.
The Clinical Psychology and Neuropsychology service will be accessed by
patients from General Medicine and Neurology including specific services to
Acquired Brain Injury, Neuropsychology, Pain, Oncology and Palliative Care
stroke, CHD and MS). These clinics will facilitate the “pooling” of resources
across broad physical health groups (e.g. long term conditions) whilst ideally
retaining membership of specialty teams as far as possible. There are also
new arrangements developed in physical health to better support/bring
psychological expertise to physical health care at a strategic level.
Provision within clinics includes individual neuropsychological and cognitive
assessment as well as psychological assessment and treatment (individual
or in groups) for functional disorders, health behaviours such as treatment
compliance, and health symptom control. The service also provides advice,
consultancy, supervision and training to health and social care staff who
work with patients with physical health problems.
Child & Adolescent Clinic Area
The clinic area will be used by Child and Adolescent Mental Health Services
(CAMHS) to improve the mental health and psychological well being of
children and young people within North Ayrshire. This service will take in
account the complexity and diversity of individual needs and should be
informed by the views of children, young people, their families and carers.
•
•
•
•
•
CAMHS offers assessment, intervention and support to children and
young people up to the age of 18 who are in full time education and
16 to those who are not.
CAMHS offers consultation and advice to a range of partner
agencies.
Provision of parenting groups
Specialist clinics
CAMHS will offer physical screening clinics, including venupuncture,
physical screening, and physical examination, in relation to ADHD
and Eating disorder pathways
The primary function of specialist child and adolescent mental health
services (CAMHS) is:
62
•
to develop and deliver services for those children and young people
(and their families and carers) who are experiencing the most serious
mental health problems. These services are provided directly by
specialist CAMHS particularly to those children and young people
whose difficulties are complex and severe.
As is clear throughout the Framework for Prevention, Promotion and Care
(2005) specialist CAMHS staff also have an important role in supporting
what the SNAP report called the “mental health capacity” of the wider
network of children’s services, namely services provided by other children’s
services around emotional well being and positive mental health. Specialist
CAMHS play a significant role in supporting colleagues to deliver on this part
of the framework requirements.
Scope of Service/Specialist Services Provided
The accommodation is described in the section entitled the Consultation &
Intervention Area in the Schedule of Accommodation.
Model of Care
Descriptive Overview
The purpose of the Consultation and Interventional Area is to improve health
outcomes by working at several different levels.
Adult clinic area (2 required)
The majority of services with be Monday-Friday 9-5pm, along with evenings
and weekends. Flexibility across morning and afternoon sessions will be
required, for instance, elderly mental health services patients will access mid
morning and early afternoon sessions.
The area should ensure:
•
•
•
•
Direct assessment and therapeutic work with patients, individually or
with families or groups;
Working in teams, including supervision of work carried out by other
professionals, staff support and joint clinical work with other
professionals;
Consultation about the care of patients; and
Teaching and training in the application of principles to improve
health care, e.g. application of cognitive-behavioural theory to
practice, communication skills.
63
Outpatient clinic – Child and adolescent services
The purpose of the outpatient clinic area for child and adolescent services
will be to provide an area where individuals are seen by a multi-professional
dedicated team.
The area should:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Create a calm and restful atmosphere and an environment which is
non-threatening;
Maximise therapeutic opportunities and the ability to relieve boredom;
Afford no undue separation of staff from patients;
Be attractive, uplifting and interesting in terms of décor, fabric,
furnishings and interior and exterior design, as well as the use of
natural materials, colour and textures;
Create a feeling of well ventilated space, maximising the use of
natural light and minimising the reliance on artificial light;
Be sensitive to the needs of physically disabled patients, visitors and
staff;
Consider space and environment and recognise that this will be
important from both the external and internal perspective;
Be imaginative and creative use of space will be vital, for example,
the avoidance of long corridors;
It is essential for the service to be flexible to the changing needs of
individuals and groups e.g. changes in conditions, gender, numbers,
cultural needs etc. The physical environment will require to be
responsive to such changes in demand;
All therapeutic rooms should be designed to enable speech privacy
and for CAMHS patients take into account varying ages between
younger and older children;
Therapy and observation rooms should have adequate storage space
to ensure equipment is securely locked away;
Adequate provision of telephone access and IT infrastructure will be
critical to effective communication;
The design of the reception admin support should be of a high quality
and allow access for people with disabilities. It is appropriate to make
the desk as friendly as possible; the inclusion of a hearing loop is a
requirement. The inclusion of children’s decor/mosaics should be
considered. ‘Friendly healthcare environments for children and
young people’ (NHS Estates, 2004) gives greater detail on designing
a child-friendly environment. Care must always be taken to ensure
that designs are suitable for all users; children, people with disabilities
and disturbed patients. (www.fairforalldisability.org);
The reception desk is the focal point of the waiting area. It requires to
oversee the waiting area but care must be taken to ensure that those
in the waiting area cannot overhear any discussions at reception.
Computer facilities will be required to monitor occupation of the
assessment rooms;
64
•
•
•
Space should be provided behind the reception desk for
photocopying, faxing, printing equipment and the disposal of
confidential waste paper etc;
The seminar room will be used for group work, for instance, for carers
and education/supervision and consultancy for staff; and
Security of the reception admin support area should include the use
of personal alarm transmitters.
Role and Function
•
•
•
•
•
•
There will be a focus on clinical/therapeutic and environmental safety
and security for the patient, general public and staff within the
service;
Security will be provided at the least restrictive level, appropriate to
the patients needs;
The environment requires to lend itself to obtrusive and unobtrusive
observation and in-keeping with Millan Principles;
The environment must be pleasant, safe and the general ambience
promotes mental and physical health well being;
It will continue to work closely and link with the community
infrastructure; and
Within the three clinic areas cluster staff will be able to work with all
age groups and across all specialties.
They will provide
neuropsychological and cognitive assessment (more sensitive than
some neuro-imaging techniques in complex presentations) as well as
psychological assessment and treatment for functional disorders.
They will deal with health behaviours such as treatment compliance,
and with health symptom control. Staff will work at all levels from
individual to organisational.
•
Bed complement
•
•
No beds will be provided in this area
Planned patient activity
Patients will access this area through planned, drop in (addiction services)
and emergency appointments. There may be times when emergency
outpatient appointments that may be required outwith appointment times but
still within the working times of the department.
Some individuals will access this area from the islands and may have
extended waits due to weather conditions or transport availability.
There will be a requirement for an area to be available to patients who arrive
unannounced and will require interaction with staff, for instance, learning
65
disabilities.
•
General principles of operation
•
•
•
•
All clinical, therapeutic and social care will be provided at the least
restrictive level appropriate to the needs of the client group;
Multi-disciplinary approach;
Clinical interventions will be evidence based and reflect current best
practice; and
Intervention will be provided in keeping with an individual’s care plan
utilising a person centred approach.
Design Synopsis
In addition to the core design synopsis/critical features, unique features to
this environment will be:
Adult Clinics (2 required)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Anti-ligature Standards;
Through doors should have an appropriate viewing panel;
Maximum use of natural and artificial light;
Maximum use of natural and artificial ventilation;
Discreet storage services;
Clinical areas that are non threatening and welcoming;
All therapy rooms should be easily observable with no blind spots;
Doorways should be wide enough to allow ease of access for
disabled access;
Calming features built into the fabric of the building; and
Young people should be involved with the design.
The waiting area will be required to accommodate some patients
during very busy periods and for family and friends who accompany
the patient to hospital. The general circulation area is the least easily
defined, as it has to provide a number of varying environments. From
a design professional’s viewpoint these are:
a waiting area for patients prior to their assessment;
a sitting area for friends and family, as some may elect to stay in the
waiting area; and
an area for enquiries, information, and providing literature/notices of
primary healthcare and local facilities
The design of the waiting area and all sub-waiting areas will include:
circulation space for wheelchair users and pushchairs;
space around seating for parking pushchairs and wheelchairs without
impeding circulation areas;
66
•
•
•
•
•
•
•
•
•
•
access to public or free phones for contacting friends, relatives, work
etc;
access to a text phone for those unable to use a public phone or a
sign indicating that staff can make one available at reception or
somewhere suitable;
if TVs are provided, they should include text and locations must not
interfere with any hearing loop systems;
information boards (a sufficient number must be provided to prevent
notices being stuck to walls, doors etc.);
access to drinking water dispensers and possibly vending machines
for healthy snacks, etc as some people arrive hungry;
the use of natural lighting where possible, although thought should be
given to shade control;
appropriate heating and ventilation;
a secure environment;
good, clear signage at appropriate height levels with maximum use of
symbols or pictorial messages to assist those with poor reading or
language difficulties in locating all services; and
Evening and weekend use of this clinical area should have
appropriate security for minimal staffing levels ie, rooms which are
not in use may be locked
Clinic Area – Child & Adolescent Services
The main key design considerations for this area will be:
•
•
•
•
•
•
•
•
There is a possibility of sharing some facilities with community
paediatrics. These include clinical areas for physical examination,
bloods, height and weights. Camhs will offer physical screening
clinics, including venupuncture, physical screening, and physical
examination, in relation to ADHD and Eating disorder pathways
There are specific issues for many of the young people seen by
CAMHS around body image, and therefore specific arrangements
would need to be in place to accommodate the needs of these young
people;
It is identified that certain synergies do exist, it is also important
CAMHS maintains its identity and status as a service within its own
right. Similarly there are also shared synergies around transition to
adult mental health services and learning disabilities;
Dedicated area for CAMHS that is discreet for children, young people
and families. Also allows young people and children the freedom to
display particular types of behaviour without being stigmatised or
chastised because other service users and/or professionals do not
understand why they are behaving in such a way. A specific CAMHS
base provides a safe environment for children, young people and
families where they are understood and empathised with;
Anti-ligature Standards;
Through doors should have an appropriate viewing panel;
Maximum use of natural and artificial light;
Maximum use of natural and artificial ventilation;
67
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Discreet storage services;
Clinical areas that are non threatening and welcoming;
All therapy rooms should be easily observable with no blind spots;
Doorways should be wide enough to allow ease of access for
disabled access;
Calming features built into the fabric of the building; and
Young people should be involved with the design.
The waiting area will be required to accommodate some patients
during very busy periods and for family and friends who accompany
the patient to hospital. The general circulation area is the least easily
defined, as it has to provide a number of varying environments. From
a design professional’s viewpoint these are:
a waiting area for patients prior to their assessment;
a sitting area for friends and family, as some may elect to stay in the
waiting area;
a designated, secure play and waiting area (sub reception) for
children, possibly out of sight from the main adult waiting area; and
an area for enquiries, information, and providing literature/notices of
primary healthcare and local facilities will be provided in the sub
reception.
The design of the waiting area and all sub-waiting areas will include:
circulation space for wheelchair users and pushchairs;
space around seating for parking pushchairs and wheelchairs without
impeding circulation areas;
access to public or free phones for contacting friends, relatives, work
etc;
access to a text phone for those unable to use a public phone or a
sign indicating that staff can make one available at reception or
somewhere suitable;
if TVs are provided, they should include text and locations must not
interfere with any hearing loop systems;
information boards (a sufficient number must be provided to prevent
notices being stuck to walls, doors etc.);
access to drinking water dispensers and possibly vending machines
for snacks, chocolate etc as some people arrive hungry;
the use of natural lighting where possible, although thought should be
given to shade control;
appropriate heating and ventilation;
a secure environment;
good, clear signage at appropriate height levels with maximum use of
symbols or pictorial messages to assist those with poor reading or
language difficulties in locating all services; and
Evening and weekend use of this clinical area should have
appropriate security for minimal staffing levels ie, rooms which are
not in use may be locked.
•
68
Corridors: Required features
•
•
•
•
Corridors should have no blind spots and allow maximum observation
Long unbroken corridors should be avoided, with the maximum use of
natural light and ventilation.
Well signposted.
Public access to upper corridors to wards should not be accessible by
the public
•
Mixed gender requirements
•
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
•
The design of the unit must comply with current legislation
Privacy and dignity requirements
•
The design of the unit must comply with current legislation
69
Required adjacencies
External
•
•
This consultation and intervention area should be located near or
adjacent to the existing outpatients department; and
The consultation and interventional area should be close to the main
entrance.
•
Internal
•
•
•
•
Therapy and observation rooms should be together within the
CAMHS clinic area;
There may be a requirement for Strathclyde Police to use the
CAMHS observation room out of hours, a request for video recording
has been asked for as this may change prior to FBC this will be
confirmed.
Ward areas infrequently but a patient could be admitted from
outpatients; and
Direct access to ambulance entrance for onward to transfer to district
general hospital.
•
Storage facilities
The following storage facilities are required for:
•
•
•
•
•
Storage for all items, for example, in the CAMHS clinic area (Medical
and non medical equipment);
Addictions service will require needle exchange locked storage
facilities;
Therapeutic equipment;
Activities store; and
Miscellaneous items.
Anticipated developments
•
•
•
During the lifespan of the building a flexible approach to design will
be required which takes into account changing models in delivery of
care;
The building should be able to meet the needs of future Information
Technology developments;
The building should be flexible in design to meet the challenges of an
ever changing and improving Health Service; and
70
•
It is anticipated that Elderly mental health services will require
expansion in the future as services are developed to meet the
increasing elderly population and the balance of care is shifted.
•
Client Group Characteristics
Age and Gender
•
•
•
•
•
Adult mental health services will offer assessment, intervention and
support of people aged 16-65 years of age;
CAMHS will offer assessment, intervention and support to children
and young people up to the age of 18 who are still in full time
education;
Elderly will offer assessment, intervention and support to people over
65 with people with a mental health problem or people of any age
with dementia;
Addictions will offer assessment, intervention and support to 16 years
of age and over; and
Learning disabilities will offer assessment, intervention and support to
16 years of age and over.
•
Admission Rates
•
Not applicable
Diagnoses
•
Not applicable
Anticipated illness-related behaviours
•
•
•
•
•
•
•
•
•
•
On occasion, some of these clients who attend this department may
show these behaviours:
Aggressive behaviour (verbal and physical);
Aimless or ritualistic behaviours;
Disinhibited behaviours;
Lack of personal risk awareness;
Suicide risk;
Unpredictable and impulsive behaviours;
Secondary physical disabilities/illnesses;
Fear and apprehension; and
Illicit drug misuse.
71
Anticipated clinical risks
•
•
•
•
•
On occasion, some of these clients who attend this department may
be at risk from the following:
Deliberate self harm;
Harm to others;
Suicidal intention;
Patients arriving at the clinic facilities without an appointment.
Patient dependency characteristics
Therapeutic Intent
Principal aims of clinical care
The adult clinic arear and chld/adolescent clinic area will allow direct
assessment and treatment for a variety of patient groups, including learning
disabilities, elderly mental health, addictions, community mental health
teams, primary care mental health teams, eating disorders, forensic
patients. Psychological assessment and treatment for more complex
psychological disorders will also take place including neuropsychological or
cognitive assessment and advice regarding diagnosis, management,
treatment and rehabilitation.
The outpatient clinic cluster for CAMHS will provide assessments and
therapeutic intervention as required from a range of multi-disciplinary staff
including Psychologists, Psychiatrists, OT, Psychotherapists, nurses etc.
•
Therapies
•
•
•
•
•
Individual and group therapies will be provided in an appropriate
setting within and out with the facility in accordance with an
individualised care plan. On a planned and ad hoc basis;
Therapies will enhance the care experience and will be focussed
upon specific agreed interventions and outcomes;
Therapy should be in keeping with recovery/Tidal Model and should
be evidence based;
Therapies should be provided by a wide range of multi disciplinary
staff; and
Therapy Examples – Anger management, Coping Skills, Anxiety
management, ‘talking therapies’ & engagement.
72
Therapeutic facilities required
•
•
Adequate space to provide therapeutic interventions as required
within the units both as groups and 1-1; and
Adequate storage space to contain therapeutic equipment will be
required within the units.
Planned clinical meetings
•
Adequate space is required to provide for a variety of clinical
meetings which will take place on a regular basis:
•
•
•
•
•
•
•
•
•
•
Multi-disciplinary meetings;
Group activities;
Consultant meeting;
Junior Doctor reviews;
Care Programme Approach(CPA) meetings;
Case conferences
Group activities; and
clinical interventions.
Other Meetings
•
•
Not applicable
Clinical risk management principles
•
•
•
•
Each case is assessed on an individual basis in relation to good
clinical risk management principles and an intervention plan devised;
Risk management for this client group is important. The environment
must be conducive to delivering the risk management plan;
Based on a proactive approach to positive risk management
(embedded within the service); and
Formalised assessment tools will be utilised and process reviewed on
an ongoing individualised basis.
73
Operational Procedures
Working day plans
•
•
•
The adult clinic area will primarily operate Monday to Friday, 9am –
5pm although evening and weekend services will be required in the
future, for instance, addiction services and primary care mental health
teams.
The CAMHS clinic area will operate Monday to Friday, 9am-5pm,
although appointments do also accommodate children, young people
and families after school. Clinicians operate from locality bases but
also see clients in their own homes or other appropriate settings
•
Staffing arrangements and shift patterns
•
The service operates as above, apart from public holidays
Admission procedures
•
•
Not applicable
Record-keeping storage
•
•
•
The service primarily makes use of the FACE system as an electronic
patient record, but requires storage facilities for paper-based
correspondence in relation to clients, and all historical records. All
paper clinical case records require to be stored within a lockable
cabinet within the records area; and
Addiction services utilise the SAMS system through the IT system
Visiting arrangements
•
Not applicable
Mealtimes/dining arrangements
•
Not applicable
Laundry facilities and linen management
74
•
Not applicable
Functional content
Investigative/Diagnostic/Treatment Capacity:
•
•
An addictions testing area and phlebotomy areas required
Outpatient Service (Number of Sessions and
specialist functions):
Each room will be used to maximum efficiency though robust and stringent
operational systems.
Specialist Technical Infrastructure Requirements
•
•
•
•
•
•
Projected direct/indirect impact of technology advances on all
services delivered from the unit including:
Access to FACE software package. The use of FACE by CAMHS
clinicians has an impact on the use of admin to support them and free
up time for clinical work;
Ehealth - Health records CHI, GP – sci-gateway (single shared
assessment, multi-agency, access referrals to services);
- Tablets, PC and wireless computing units to access all
standard and specialist clinical and operational systems
Personal alarm system
75
Projected Future Activity
Within the Adult clinic area it is expected to have 1000 new referrals and
3000 return patients, along with carers group work sessions and staff
training/supervision.
•
Within the Child & Adolescent clinic area the following applies:
•
•
•
•
•
•
•
•
•
•
•
•
•
Over the past year we have had a 9% increase in referrals;
Over the past year there has been a 5% increase in referrals in the
North;
HEAT targets;
Commitments 10 and 11 – Delivering for Mental Health;
Recovery approach;
Tidal Model;
18 week RTT;
Independent Assessment Framework (IAF);
Partnership Forums;
Referral rates over the past year have increased in the North locality
by 5% from 479 to 518. This is expected to continue and increase.
There will also be an increase in staff numbers. Within the next year
the North Locality will have an additional 2 CAMHS clinicians. With
the promise of increased funding it is anticipated that the team will
continue to grow;
Referral processes are being reviewed in the service. The age range
will be broaden from 0-18, which will increase the number of referrals;
Development of pathways for ADHD, eating disorders, psychosis; and
Development of nurse prescribing, may increase clinic type work
loads.
76
Key Relationships with Other Departments
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Appropriate Physical health services e.g. Douglas Grant
Rehabilitation unit, Oncology, Stroke, etc
Primary mental health link workers in schools
Pan Ayrshire alcohol project
Independent Assessment Forum
Partnership forum
Advocacy
CAMHS
Child protection
Childcare services
Community Mental Health Teams
Education and universities
GPs
Hospital Social Work department
Learning Disabilities
Local Authorities Social Services, housing, benefits agency, tenancy
support, job centre plus, citizens advice service, pet fostering etc
Medical staff
Others Allied Health Professionals
Pharmacy
Police
Psychology
Service user groups/carer groups
Standby Social Work services
Voluntary sector
Close to
Reason
Category*
Adult mental
health services
Transition from CAMHS to adult
services can be facilitated by closer
proximity
important
Learning
disabilities
Transition from CAMHS to adult
services can be facilitated by closer
proximity, some links already exist
and need to be maintained
Important
Paediatrics
Some links already exist and need
to be maintained
Important
Main entrance
To allow easy access for elderly
mental health patients
Important
Central walk-in
entrance
To allow patients, family and friends
to access the café area/coffee
shop/retail
Important
77
Future Service Delivery Risks
•
•
•
•
•
•
•
•
•
•
•
•
•
Changes in practice;
Changes in diagnostic pattern for admission eg personality disorders,
challenging behaviour, Autistic Spectrum Disorder (ASD), brain injury,
Alcohol Related Brain Damage (ARBD) and changes in diagnostic
pattern for admission;
Demographic changes;
Integrated Care Pathways (ICP);
HEAT targets – readmission rates, suicide prevention etc;
Positive risk taking;
Other services developing;
Bed availability and bed blocking due to the lack of alternative
community provision;
Activity levels unpredictable;
Future service demand is uncertain. This new provision needs to
reflect change in trends and be adaptable to future need;
Service Level Agreements (SLA) out of area no longer available for
extra-contractual referrals therefore service would again have to
adapt to that need;
Patients arriving at the clinic facilities without an appointment; and
People attending when intoxicated or under the influence of drugs.
78
Appendix I – Multi-function ECT/Minor
Surgery/Therapy Area
Introduction and outline of services
Departmental Function
This area will have many multi-functional uses. In the first instance it will be
an ECT suite for approximately two days/week, the description below
describes the function of this service. When this area is not required for ECT
purposes, it is proposed that this area could be used for a variety of uses,
including a minor procedures area by GPs, AHP therapy area and by the
addictions service to offer a tolerance testing.
All the above services are described below under separate departmental
functions.
ECT Suite
The scope of the ECT department is to provide a safe, effective and
progressive ECT facility, delivered by professionals who have experience
and a specialised knowledge of the service.
ECT is effective in a wide range of psychiatric disorders but it is generally
accepted as a first line treatment in severe or life threatening depression
and treatment resistant depression.
The basic aim of ECT treatment is to induce a generalised cerebral seizure
of a tonic–clonic or grand mal type, and to do so with an electrical dose that
is sufficient to maximise the clinical efficacy of treatment, but not so high
that it needlessly causes cognitive adverse effects of treatment.
The department function is:
•
•
•
•
To provide effective, up to date and safe ECT treatment for the
Ayrshire and Arran patient population;
Maintain exemplary standards for service delivery through existing
clinical governance structures;
To provide an educational and training resource for junior doctors and
nursing staff; and
To encourage audit and research projects in ECT as well as
contributing data to the Scottish national ECT audit project.
79
Minor procedures area
Within this area, minor lump, bump surgery may take place when rooms are
available.
•
•
AHP Therapy Area
•
The shared space will be used by Allied Health Professionals to provide a
rehabilitation and enablement service to inpatients. These services will
include:
•
•
•
•
Assess, diagnose, treat and refer patients to other services;
Play a central role in promotion of health and wellbeing;
Liaise with other clinicians and provide a specialist service;
Teach, train and mentor other clinicians, students patients and
carers; and
Undertake research and development to improve clinical practice.
•
•
Addiction services
This area when available could be used by Addiction services for tolerance
testing purposes. This would allow the service to bring patients in to a safe
observation area to titrate prescribed methadone.
Scope of Service/Specialist Services Provided
The accommodation is scheduled in Mental Health Services and is
described in the section entitled ECT Suite/AHP Area/Minor Procedures
Area in the Schedule of Accommodation.
Model of Care
Descriptive Overview
ECT
ECT is used as a treatment for a minority of patients with severe and/or
treatment resistant mental illness. It is delivered to a high standard as a
result of collaboration between ECT clinic staff, the anaesthetic department
and the referring ward team. Service standards are subject to scrutiny from
a number of outside agencies/bodies and this provides an incentive for
ongoing audit, training and development of the service.
Therapy Area
80
The therapy area will provide a model of care that will be underpinned by the
philosophy and principles in Co-ordinated, Integrated and Fit for Purpose: A
Delivery Framework for Adult Rehabilitation in Scotland and the principles
set out in AHPs as Integrators of Care.
•
•
•
•
Access
Dignity and the patient as a person
Integrating care and partnership
Choice and personal control
Addictions
This area when available could be used by Addiction services for tolerance
testing purposes. This would allow the service to bring patients in to a safe
observation area to titrate prescribed methadone.
Role and Function
ECT
•
•
•
•
•
•
•
•
All areas should have a source of natural light;
Preparation room must accommodate a trolley bed;
Treatment room must be adequate;
Space to allow a trolley bed to be wheeled in from the preparation
room and out to the recovery room;
Space to allow a minimum of 6 staff to work around the patient on the
trolley bed;
Space to accommodate the anaesthetic equipment, the ECT
equipment used during the treatment session, emergency trolley plus
supplies used in the course of a treatment session;
Treatment Room - Separate room next to preparation room that will
accommodate trolley bed and all necessary equipment;
Piped in oxygen and suction, ECT machine and back up (EEG
facility), Unilateral and bilateral probes, Anaesthetic machine
(ventilator) (suction) to meet remote site requirements, Patient
monitors (1 for each patient with ECG facility and 1 in treatment
room), Suction points or machines (1 for each patient), Electronic
thermometers x 4, Laryngoscopes x 3, Glucometer x 2, 12 lead ECG
machine x 1, Emergency trolley x 1, Surgical trolleys x 6, First aid
boxes x 1, Tilting trolleys that carry oxygen and have i/v stands x 8,
Ambu-bag x 1, Automated defibrillator x 1, Theatre stools x 8, Clocks
with second hand, Stop watch, All necessary sundries and
81
•
•
•
•
•
•
emergency supplies;
Storage space, telephone, IT system.
Moving and handling
(wheelchair). Natural light. Theatre light, Infection control. Health &
safety;
Recovery Area should be a separate room next to treatment room
that accommodates trolley beds for maximum through flow of
patients. Storage space. Telephone. IT system. Natural light.
Ability to adjust lighting levels for individual recovery bay areas. Piped
in oxygen and suction. Infection Control. Manual Handling. Health &
Safety. Observation;
Recovery room size must fit 7 trolley beds plus monitors for each
recovery patient, stool for nurse caring for each recovery patient,
equipment as above;
Small dedicated kitchen space for preparation of snacks;
Dedicated office space; and
ECT requires storage space for bulky sundries e.g tubing for
anaesthetic machines, currently stacked in large boxes in recovery
areas of existing clinics inappropriately. If treatment area is to be
used for purposes other than ECT, as proposed, then the ECT
machine and related ECT-specific equipment needs to be securely
stored outwith the treatment room. When the recovery area is being
used for non-ECT purposes, the monitors must be securely stored
elsewhere and trolley beds may need to be moved elsewhere within
the suite.
AHP Therapy area
•
•
Storage of trolleys and equipment will be required when facility not
being used as ECT suite
Most therapeutic activity will take place in the recovery room (stage
1), treatment room and recovery room (stage 2)
•
Addictions
If using this area by the addiction service, the following rooms would be
required for patients:
•
•
•
•
Preparation area (patients should be able to access this area to wait);
Disposal/sluice/test area (this area will be used to undertake drugs
screen urine analysis prior to commencement of treatment);
Recovery room (stage 2) Treatment area (this area will be used to
dispense and observe titration of prescribed medication – for up to 4
hours). It would be beneficial if there could be diversional activities
available in this area, ie. flatscreen TV); and
Office (access for Doctor and associated nursing staff – maximum of
3 staff at any one time).
82
Bed complement
•
7 treatment spaces
Planned patient activity
ECT Suite
Using data gathered for the last 5 years of clinic activity to estimate what the
likely future activity of a single clinic would be, we note that there was a drop
in total number of patients treated in 2008. Despite this, when looking at
data over a three, four or five year timeframe, statistics remain consistent:
The future ECT clinic in Ayrshire would be expected to treat an average of
3.52 to 3.68 patients per day of operation, median number of patients = 3,
mode = 2. There is a notable variation in the numbers of patients treated
and if we use the 90th percentile to estimate the maximum capacity of the
clinic, this would be 7 patients using data for 3 or 5 years, or 6 patients using
the 4 year data. Our preference would be for a clinic with 7 treatment
spaces.
AHP Therapy area
This area would be utilised to conduct therapeutic group sessions such as
anxiety management. May also be used for relaxation groups and health
education groups.
Addictions
It is anticipated that in the future this service could use the rooms during two
sessions, during the day and possibly into the evening in the future. There
would be a maximum of 3 patients at any one time. Over the week there
would be approximately 3 patients seen over the 2 sessions (twice over 2
days).
83
General principles of operation
Design Synopsis
ECT Suite
This area should have a discrete entrance.
In addition to the core design synopsis/critical features, unique features to
this environment will be:
Waiting Area
To accommodate maximum through flow of patients and escorting staff.
Comfortable, soft furnishings. Natural light, toilet area. Television, music
system. Magazine storage.
Separate Kitchen Facility
To accommodate space for cutlery, crockery, kettle, toaster and the making
of light snacks. To meet food and hygiene requirements Infection Control
and Health and Safety.
Preparation Area
Separate room that will accommodate trolley bed storage space, telephone.
Natural light. Hand-washing/moving and handling (wheelchair). IT system.
Treatment Area
Separate room next to preparation room that will accommodate trolley bed
and all necessary equipment (see list). Storage space, telephone, IT
system. Moving and handling (wheelchair). Natural light. Theatre light,
Infection control. Health & safety.
Recovery Area
Separate room next to treatment room that accommodates trolley beds for
maximum through flow of patients. Storage space. Telephone. IT system.
Natural light. Ability to adjust lighting levels for individual recovery bay
areas. Piped in oxygen and suction. Infection Control. Manual Handling.
Health & Safety. Observation.
Office Space
84
Telephone. IT system. Filing cabinets. Desks. Chairs
ECT co-ordinator requires the use of this office throughout the working week
as they deal with clinic related admin, enquiries, planning, etc outwith clinic
sessions.
Storage Space
Separate room / Separate gas storage
Toilet Area
Disabled facility with shower.
Linen
Separate clean storage.
Storage room for:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Equipment (medical)
Piped in oxygen and suction
ECT machine and back up (EEG facility)
Unilateral and bilateral probes
Anaesthetic machine (ventilator) (suction) to meet remote site
requirements
Patient monitors (1 for each patient with ECG facility and 1 in
treatment room)
Suction points or machines (1 for each patient)
Electronic thermometers x 4
Laryngoscopes x 3
Glucometer x 2
12 lead ECG machine x 1
Emergency trolley x 1
Surgical trolleys x 7
First aid boxes x 1
Tilting trolleys that carry oxygen and have i/v stands x 8
Ambu-bag x 1
Automated defibrillator x 1
Theatre stools x 8
Clocks with second hand
Stop watch
All necessary sundries and emergency supplies
Equipment (manual handling)
•
•
•
Pat slides
Sliding sheets
Hoist
85
Therapy Area
When the area is being used as a Therapy area the following equipment will
require to be accessed from lockable cupboards:
•
•
Mats for relaxation / mindfulness groups
Resources for therapeutic group sessions – including relevant
presentation materials, activities
•
Addiction service
•
If Addiction service uses this area, Addiction services will require a cupboard
for the following items:
•
•
Storage facility for controlled drugs
Corridors: Required features
•
•
•
Corridors should have no blind spots and allow maximum observation
Long unbroken corridors should be avoided, with the maximum use of
natural light and ventilation.
Well signposted
Mixed gender requirements
•
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
•
•
The design of the facility must comply with current legislation
The building should be sensitive to the needs of physical and sensory
disabled patients, staff and visitors.
Privacy and dignity requirements
•
The design of the unit must comply with current legislation
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
86
Required adjacencies
External
ECT
•
•
•
Clinical taxis – Occasionally utilised for transferring patients to and
from the ECT suite for treatment;
Private healthcare facilities – An Infrequent event which in the past
has been provided through a service level agreement; and
Scottish Ambulance Service – Ambulances are utilised regularly for
transferring patients to and from ECT suites on the day of treatment.
•
Therapy area
• Not applicable
•
Addiction services
•
•
•
Not applicable
Internal
ECT
•
•
•
•
•
Elderly Mental Health wards and acute adult mental health wards;
Ambulance bay;
Taxi / drop off area;
Pharmacy services – provide all drugs including anaesthetic agents
therefore close links are essential; and
Medical Physics and Estates – Close links required for Maintenance
and calibration of equipment.
Therapy area
• Internal inpatient ward areas – who may be in the night attire; and
• Relatively close to outpatients entrance.
•
Addiction services
•
•
Not applicable
87
Storage facilities
The following storage facilities for are required for:
ECT
•
•
•
•
•
•
Separate Gas storage (oxygen and suction) (if piped not provided)
Clean laundry storage space
Waiting area – magazine storage
Preparation Area - Separate room that will accommodate trolley bed
storage space
Recovery Area – storage space
Linen – storage space
Therapy area
•
•
•
•
Storage for mats (either mobile rack or cupboard space)
storage for small pieces of gym equipment eg balls, hoops, bean
bags
storage for electrotherapy equipment eg ultrasound machines,
interferential machines, TENS
storage for walking aids (unless there will be central storage for large
pieces of equipment)
storage of materials for therapeutic group activities
storage of audiovisual equipment
•
•
•
Addiction services
•
•
Small cupboard for storage space to hold specimen bowls, latex
gloves, drugs screens and clinical waste bin.
Anticipated developments
•
Not applicable
Client Group Characteristics
Age and Gender
ECT
88
The service accepts referrals from working age and old age psychiatry
services. Patients suffering from severe depression, or other mental illness
for which ECT could be indicated. A medical assessment is completed and
risk assessed and fit for anaesthesia.
Therapy Area
All patients over 16 years of age.
Addiction services
All patients over 16 years of age.
Admission Rates
The new site at ACH will be regarded as isolated for the purposes of
anaesthetic input. Assessment of patients will be even more rigorous than
in the past. Patients assessed as being of higher anaesthetic risk may need
to receive their treatment in theatre space at the DGH site – probably
Crosshouse. Some equivalent or borderline cases in the past would have
had treatment in the Crosshouse clinic.
If more complex cases are treated in the community setting, we may see
more outpatient ECT.
Diagnoses
ECT
•
The majority of patients at ECT suffer from a depressive illness.
89
Anticipated illness-related behaviours
•
Agitation and distress causing some disturbed behaviour before or
after treatment with ECT e.g. post-ictal confusion.
•
Patients may exhibit challenging behaviour and may be experiencing
a degree of physical ill health.
Anticipated clinical risks
•
Anaesthetic input to the ECT clinics is in accordance with the
standards set by the AAGBI. Some anaesthetic pre-assessment of
patients is required when potentially high-risk patients come for
treatment from the psychiatric wards or the DGH wards. The
outcome of that pre-assessment may be the involvement of other
hospital specialists in optimising a patient’s physical state prior to,
and during a course of treatment.
Therapy Area
•
No specific clinical risks
Addiction services
•
Possible risk of overdose of contra-indication of
medication with previous ingested substances.
prescribed
90
Patient dependency characteristics
Therapeutic Intent
Principal aims of clinical care
ECT proposals
The psychiatric department have expressed their desire to have ECT
facilities located in the new development at the Ayshire central site. Within
Crosshouse context this will involve a significant change from current
practice. At present ECT is carried out within the main hospital site on a
Monday and Friday mornings. Anaesthesia for these sessions is currently
covered by the duty anaesthetist for that day. In most instances this will be
a consultant anaesthetist but occasionally an associate specialist or staff
grade will provide the anaesthetic cover.
Moving to a distant site will involve changes in several areas.
Staffing
Pharmacy stock
Equipment supply and maintenance.
Emergency equipment.
Protocols for Contingencies.
1. Staffing.
The current compliment of staff required for a current ECT session within
Crosshouse is an Anaesthetist, Consultant Psychiatrist, Anaesthetic nurse
and 2-3 psychiatric nurses specialising in ECT. Recent documentation from
national bodies had suggested that a fully trained recovery nurse should
also be present to manage the transition of the patient from first stage
recovery to second stage recovery.
Moving to the Ayrshire central site would not alter these requirements but
the logistics would change significantly.
Anaesthetic cover.
As stated above the ECT sessions are currently covered by the duty
91
anaesthetist. Moving to the Ayrshire central site would necessitate the
session itself, including travelling time, becoming a fixed clinical commitment
of a consultant anaesthetist. Including travelling time to and from the bass
hospital this would approximate to 1.5 PAs of direct clinical care. This
clinical session would be required twice a week. The Ayrshire central site
would be viewed as a distant site and as such should ideally be covered by
a consultant. Clearly provision would need to be made for annual or sick
leave and there may be instances when consultant cover could not be
guaranteed. If no consultant cover could be supplied then an associate
specialist could, under these circumstances, cover a distant site. However
this would have to be assessed from a risk point of view before
implementation. The source of funding for these consultant sessions would
need to be discussed at management level.
Nursing cover., Anaesthetic Nurse, Recovery Nurse.
Minimum of 3 Psychiatric nurses skilled in the management of patients post
ECT.
2. Pharmacy Stock.
Currently in Crosshouse the ECT suite has a well stocked albeit basic
selection of drugs. This does not pose any major difficulty because of the
proximity of the pharmacy department and theatres from which emergency
drugs could be retrieved if required.
New site would require pharmacy stock similar to emergency theatres in Ayr
and Crosshouse.
Special care and consideration would need to be given to rarely used
expensive drugs such as Dantrolene and Sugamadex.
Inevitably there would be some waste from this stock because in most ECT
sessions use of these drugs would be minimal.
3. Equipment Supply and maintenance.
The ECT suite should be fitted out to the current standard of an anaesthetic
room. Piped gas should be present with cylinder back up.
The anaesthetic machine including mechanical ventilation and potential for
volatile anaesthesia.
Machine regularly serviced and maintained by medical physics.
Failure of machine would necessitate cancelation of list.
Airway trolley to standard of emergency airway trolley in theatre 4
Crosshouse.
92
Discussion would be required about the need for airway rescue devices
such as jet ventilation and a video laryngoscope.
The need for such equipment might be offset if difficult patients are given
the first course of treatment within either Ayr or Crosshouse hospital.
A stock of central and arterial lines including the facility to monitor these
should be in place.
2 infusion pumps would be required for emergency purposes.
A defibrillator with pacing options.
A selection of intravenous fluids.
Intraoperative and post operative monitoring should meet the minimum
criteria as set out by the association of anaesthetists. Intraoperatively this
would include capnography. Post op saturation, respiratory rate, heart rate
and BP would require to be monitored.
4. Emergency equipment
The requirements for this are covered in the equipment section.
5. Protocols for Contingencies.
Staff involved in the delivery of ECT should be familiar with emergency
contingencies for life threatening anaesthetic emergencies. This would
include Advanced life support guidelines, treatment of malignant
hyperpyrexia, treatment of anaphylaxis, emergency airway management in
the can’t intubate can’t ventilate scenario and management of status
epilepticus.
Regular training and assessment with logbooks of training should be kept for
all staff involved.
As can be seen from the above moving to a distant site requires careful
planning and consideration of the costs and benefits involved.
ECT suite should consist of connected rooms. The first area is a waitingroom, proposed number of waiting spaces 10 and a wheelchair bay where
patients are received and welcomed into the unit. This is connected to a
further room where patients are prepared for treatment, for example
removing dentures and speaking in privacy to the anaesthetist and nurse,
93
without the presence of the equipment in the treatment room. Patients then
move onto the third area, the treatment room, where ECT is administered,
followed by the recovery room which is directly adjacent and connecting.
This configuration is based on guidance from the Royal College of
Psychiatrists.
•
Therapies
•
Not applicable
Therapeutic facilities required
•
Not applicable
Planned clinical meetings
•
Not applicable
Other Meetings
ECT
•
Developing a cognitive screening and rehabilitation role for the ECT
clinic staff will result in some one-to-one sessions between staff and
former patients. Anticipate patients will be offered follow-up at 3 and
6 months post ECT, but not all will take this up. Patients identified as
having some difficulties will have sessions with staff to look at
cognitive rehabilitation (e.g. six 30-60min sessions).
Therapy area
•
Not applicable
Addiction services
•
Not applicable
Clinical risk management principles
94
•
•
•
•
•
Risk management for this client group is important. The environment
must be conducive to delivering the risk management plan;
Based on a proactive approach to positive risk management
(embedded within the service);
Formalised assessment tools will be utilised and process reviewed on
an ongoing individualised basis;
On admission each patient is assessed in accordance with a
recognised risk assessment tool; and
Based on this initial risk management plan is developed which will
also determine the person’ observation status.
Operational Procedures
Working day plans
ECT
We have specifically asked for treatment sessions to be on Tuesday and
Friday mornings, for clinical reasons. This would need to change when a
public holiday falls on a Tuesday or Friday, so some flexibility of use will be
needed. If patient numbers increase and exceed our recovery capacity, we
may need to have ECT on a third session during the working week.
The ECT co-ordinator would be working in the office at times outwith the
ECT clinic treatment sessions.
Outpatients attending for ECT i.e. arriving on the morning of treatment and
returning home with an escort later the same day, will need to spend longer
in the department recovering before they go home. This may mean we use
some parts of the unit e,g, the waiting area (recovery stage 2) after the
treatment session has officially finished at 1300hrs.
Morning - 0930hrs - 1300hrs
Afternoon - 1330hrs – 1700hrs
Therapy area
•
Dependent on availability of the room
Addiction services
•
Access to rooms, two consecutive afternoons a week.
95
Staffing arrangements and shift patterns
ECT
In the new facility, the ECT team will consist of the nurse co-ordinator (a
fulltime post) plus depute and a further 3 core staff with other ward staff
drafted in when necessary.
Junior medical staff will attend the clinic to deliver treatment for training
purposes. They will do this in blocks of 3 weeks. A consultant psychiatrist
will be present at all treatment sessions in the new clinic facility.
The anaesthetic team will be present for the duration of the treatment
session.
AHP Therapy Area
•
Existing Mental Health OT staff would utilise the Therapy Area.
Addiction services
•
Maximum of three staff, one medical and two nursing.
Admission procedures
ECT Admission Criteria for wards
•
The ECT department only accepts referrals from secondary care
mental health services. The decision for treatment is often complex
and requires to be made by experienced mental health clinicians,
usually the patient’s own consultant psychiatrist and inpatient team.
The service accepts referrals from working age and old age
psychiatry services.
Therapy area
•
Therapists accept referrals from working age and old age psychiatry
services.
96
Addiction services
•
Via planned appointment.
Record-keeping storage
•
Not applicable
Visiting arrangements
•
Not applicable
Mealtimes/dining arrangements
•
Not applicable
Between meal snacks and access to beverages
ECT
Once patients have recovered from anaesthesia, they will have a snack and
a drink e.g. tea and toast, prepared for them in the unit. Having consumed
this and recovered a little further, they will mostly return to their ward for
ongoing observation (note some patients are “outpatient”).
Laundry facilities and linen management
•
Not applicable
Adult Recreational Facility
•
Not applicable
97
Functional content
Number of Inpatient Beds/Treatment Spaces
ECT
•
Therapy area
•
•
Floor space for 6 – 8 mats if used for relaxation
Up to 12 people if seated for group work
Addiction services
Access to the following rooms:
•
•
•
•
Preparation area (patients should be able to access this area to wait);
Disposal/sluice/test area (this area will be used to undertake drugs
screen urine analysis prior to commencement of treatment);
Recovery room (stage 2) Treatment area (this area will be used to
dispense and observe titration of prescribed medication – for up to 4
hours). It would be beneficial if there could be diversional activities
available in this area, ie. flatscreen TV); and
Office (access for Doctor and associated nursing staff – maximum of
3 people).
Investigative/Diagnostic/Treatment Capacity:
ECT
•
The ECT service would not be possible without input from the
Anaesthetic departments of both Crosshouse and Ayr Hospitals. In
addition to providing a service on the day of treatment, the consultant
anaesthetists provide advice and if necessary pre-anaesthetic
assessment of patients who may be at higher risk of complications
and the anaesthetic team also provide a service for the one or two
patients each year who require treatment in a more acute setting e.g.
emergency theatres.
Therapy Area
•
Not applicable
Addiction Services
98
•
Addiction services would require use of the Disposal/sluice/test area
to undertake drugs screen urine analysis prior to commencement of
treatment.
Outpatient Service (Number of Sessions and
specialist functions):
ECT
•
The first area is a waiting-room (waiting spaces for 10 people and
wheelchair) where patients are received and welcomed into the unit.
This is connected to a further room where patients are prepared for
treatment, for example confirming identity, consent to treatment,
attaching monitoring equipment, removing dentures and speaking in
privacy to the anaesthetist and nurse, without the presence of the
equipment in the treatment room. Patients then move onto the third
area, the treatment room, where ECT is administered, followed by the
recovery room which is directly adjacent and connecting. This
configuration is based on guidance from the Royal College of
Psychiatrists.
Therapy Area
•
Not applicable
Addiction services
Access to the following rooms:
•
•
•
•
Preparation area (patients should be able to access this area to wait);
Disposal/sluice/test area (this area will be used to undertake drugs
screen urine analysis prior to commencement of treatment);
Recovery room (stage 2) Treatment area (this area will be used to
dispense and observe titration of prescribed medication – for up to 4
hours). It would be beneficial if there could be diversional activities
available in this area, ie. flatscreen TV); and
Office (access for Doctor and associated nursing staff – maximum of
3 people).
99
Specialist Technical Infrastructure Requirements
•
•
Piped in oxygen and suction required
ECT suite should have access to a networked computer allowing
laboratory and imaging results to be checked prior to treatment.
•
Therapy Area
• Not applicable
•
Addiction services
•
•
•
Access to emergency equipment.
Projected Future Activity
ECT
Difficult to predict, as multiple factors at work – see below.
Although combined the Ayrshire and Arran ECT clinic forms the second
largest clinic in Scotland we have seen a general decline in patient referrals
over the last decade. This pattern is evident across the country and is partly
due to considerable advances in antipsychotic and antidepressant
medication. This fall has not been seen in the practice of old age psychiatry,
which makes still disproportionately high use of the ECT service. There are
several possible reasons for this. Older adults may be more likely to suffer
from the sorts of illnesses which respond to ECT. Refusal to eat or drink,
severe psychosis and stupor may be more common in older age groups.
The greater speed of response to ECT may lead to it being used
preferentially in people whose poor physical health accentuates the urgency
of treatment. Additionally there may be differences among older patients in
their attitudes towards, or acceptance of, ECT.
Our population is aging: it is estimated that the number of elderly people in
Ayrshire will increase from 67000 to well over 80000 in the next ten years.
Clearly the service requires to consider the potential increase in demand for
ECT in this high usage group. It also generally accepted that elderly patients
over a course of treatment require a greater number of treatments when
compared to their younger counterparts, yet another factor that needs to be
taken into account when considering the number of future treatment places.
Increasingly, we are seeing a preference for unilateral ECT treatment and a
slow move away from bilateral stimulation, particularly in the elderly, in order
100
to minimise cognitive side effects. It is recognised that unilateral ECT often
requires more treatments when compared to bilateral stimulation which
again needs to be factored into future service capacity.
Patient numbers are declining throughout Scotland. Potentially this could be
extrapolated to a point where the number of Ayrshire patients needing
treatment was so small that even one clinic was no longer viable and
patients would need to be sent elsewhere e.g. to Glasgow for treatment.
The proportion of elderly patients is increasing. The use of unilateral
treatment as opposed to bilateral is being encouraged. Both of these will
result in the smaller numbers of patients having slightly greater numbers of
treatments per course of ECT.
Therapy Area
•
Not applicable
Addiction services
•
It is anticipated that in the future this service could use the rooms
during two sessions, during the day and possibly into the evening.
There would be a maximum of 3 patients at any one time. Over the
week there would be approximately 3 patients seen over the 2
sessions (twice over 2 days).
Key Relationships with Other Departments/NHS
Ayrshire and Arran /Social Services/Social
Work/Local Authority Services
Close to
EMH wards and acute
adult wards
Reason
Ease of transfer of
patients to and from
treatment session
Category*
Desirable
Ambulance bay
Emergency transfer of
critically ill patient to ITU
Important
Taxi / drop off area
Ease of transport of
patients from Ailsa and
any outpatients attending
for treatment
Desirable
101
Hospital pharmacy
Speedy access to
medications in
emergency
Important
Future Service Delivery Risks
ECT
•
•
•
The new site at ACH will be regarded as isolated for the purposes of
anaesthetic input. Assessment of patients will be even more rigorous
than in the past. Patients assessed as being of higher anaesthetic
risk may need to receive their treatment in theatre space at the DGH
site – probably Crosshouse. Some equivalent or borderline cases in
the past would have had treatment in the Crosshouse clinic; and
If more complex cases are treated in the community setting, we may
see more outpatient ECT.
Therapy Area
•
Not applicable
Addiction services
•
Possible risk of overdose of contra-indication of
medication with previous ingested substances.
prescribed
102
Appendix J - Pharmacy/Dispensary
Introduction and outline of services
Departmental Function
•
The Pharmacy Department will serve both mental health and
community hospital services.
It will provide clinical pharmacy
services, dispensing and ad hoc supplies to both services. Bulk
deliveries will be provided from Crosshouse Hospital Pharmacy
Department direct to the wards. Estimated pharmacy staffing would
not be expected to exceed 20, but is dependent on the pharmacy
services required by the community hospital element. The Pharmacy
requires a central location for access to all in-patient wards and also
to the consultation and interventional area and outpatient clinics.
Scope of Service/Specialist Services Provided
The accommodation is scheduled in Mental Health Services and is
described in the section entitled Pharmacy/dispensary in the Schedule of
Accommodation.
Model of Care
Descriptive Overview
Pharmacy cover two main elements of service provision:
• The provision of a clinical pharmacy service to patients and wards
• The supply of medicines to wards and to patients on pass and on
discharge from hospital.
The level of service provision will be dependent on case mix. Current
services do not necessarily reflect what will be required when the new
community hospital is fully operational.
The main supply function will be managed from the central point at
Crosshouse Hospital. The clinical and dispensing services can be provided
in association with the mental health pharmacy arrangements subject to
staffing and accommodation etc.
103
The new pharmacy department will support all patients on the North
Ayrshire Community Hospital site.
Specialist clinical pharmacy services will be provided by the Mental Health
Pharmacy Team (MHPT, currently based at Ailsa Hospital) to patients
across NHS Ayrshire and Arran. Inpatient services are provided as part of
the multidisciplinary team, with support to community services as
appropriate. All aspects of mental health services will be supported:
• Adult inpatients and community services/IPCU/Low Secure/forensic
• Elderly mental health
• Addictions
• Learning Disabilities
• CAMHS
A dedicated area-wide clozapine pharmacy service is also provided by the
MHPT, currently from Ailsa Hospital. This service will now be centrally
provided from the new pharmacy at the NACH site.
The clinical pharmacy and dispensing requirements for the community
hospital will be provided in association with the mental health pharmacy
arrangements, subject to staffing and accommodation.
Role and Function
(1) Community Hospital element
At present all medicines utilised on the Ayrshire Central site are supplied
from Crosshouse Hospital. This follows the upgrading of the pharmacy on
the Crosshouse site and the closure of the pharmacy on the Ayrshire
Central Hospital site. This is currently insufficient activity on the Ayrshire
Central site to merit a pharmacy department.
A clinical pharmacy service is provided to the Ayrshire Central site from
Crosshouse Hospital. A technician top-up service is also provided from
Crosshouse.
(2) Mental Health Services
104
Dispensing and Medicine Supplies
The MHPT is based at Ailsa Hospital and provides all dispensing
requirements (pass, discharge, outpatient prescriptions, self-medication
supplies) to the Ailsa and Arrol Park sites. Ad hoc orders are also provided
by Ailsa Hospital Pharmacy to these locations.
Pharmacy technicians from the MHPT provide a comprehensive ward top up
service to MH services at Ailsa and East Ayrshire Community Hospital and
also to Arrol Park. Bulk orders to Ailsa Hospital, Arrol Park and mental
health beds at EACH are currently provided by Ayr Hospital Pharmacy, while
Crosshouse Pharmacy provides bulk orders to MH beds at Crosshouse (1D
and 1E) and Ayrshire Central Hospital (Pavilions 1 and 2).
Clozapine Service
The NHS Ayrshire and Arran centralised clozapine pharmacy service is also
provided from a team based at Ailsa Hospital Pharmacy, supplying
clozapine to approximately 230 outpatients throughout Ayrshire. Clozapine
is also supplied by this team to inpatients at Ailsa and Arrol Park. In
addition, clinical advice including specialist therapeutic drug monitoring is
provided by the clozapine pharmacist and specialist clinical pharmacists.
Specialist Mental Health Clinical Pharmacy Services
Specialist mental health clinical pharmacy services are provided by
pharmacists to all services within mental health. Each Senior Clinical
Pharmacist has a specialist responsibility, e.g. Elderly Mental Health, Adult
Mental Health, Learning Disabilities, etc. The pharmacists provide specialist
advice and pharmaceutical care as members of the multidisciplinary teams.
Mental health clinical pharmacy services are currently provided by the
MHPT to Ailsa Hospital, Arrol Park, EACH, Ayrshire Central and Crosshouse
sites, with input to CAMHS and forensic services.
With the new MH facility being provided at Ayrshire Central, it is important to
note that a satellite clinical pharmacy service beds remaining on the Ailsa
Campus will require to be retained with appropriate access to desk space/IT.
There would be no requirement for separate dispensing/supply services to
be provided at the Ailsa site and further discussion is required as to how
these services will be delivered.
105
(3) Outpatient department
The hospital pharmacy department provides an outpatient dispensing
service for patients requiring medication immediately as prescribed by
psychiatrists at outpatient clinic. Location of the pharmacy relative to
outpatient clinics would require to be considered, along with facilities for
pharmacy staff to counsel patients about their medicines.
An additional consideration would be the future model for patients
prescribed clozapine. One potential development would be the use of ‘near
patient testing’ and ‘one stop dispensing’ where clozapine patients would
have their blood taken, analysed immediately onsite and be given their
medication in one visit, dependent on the result. Accommodation
requirements and appropriateness of having of such a facility on the new
NACH campus would need to be considered in consultation with nursing
and medical colleagues.
Pharmacists also require appropriate accommodation to interview and
counsel patients (separately from the prescription counselling service) and it
would improve the current situation if outpatient accommodation could be
utilised for this purpose.
(4) Medical gas provision
As expected, we are anticipating a mixed model, with MH wards using
cylinders and the community hospital would be expected to utilise piped
gases, in keeping with East Ayrshire Community Hospital and Girvan. We
have discussed that ECT would preferably use piped gases, so it would be
helpful to consider the siting of the ECT suite in relation to the community
hospital facilities with respect to piping requirements. Additional
consideration would need to be given to what gases would be required and
anticipated usage as this would influence how the piped gases would be
provided.
Bed complement
•
Not applicable
Planned patient activity
•
•
•
Medication usage will increase in the future;
Potential remodelling of the clozapine service with near-patient
testing/one stop dispensing; and
Pharmacy activity in the community hospital (outpatient/clinical) will
be determined by the range of specialties provided.
106
General principles of operation
Design Synopsis
The future development of mental health services will have an impact on the
pharmacy accommodation and service needs of the site. A fully functioning
pharmacy providing dispensing and clinical services will be required. The
service needs of the new community hospital should be able to be provided
from this pharmacy, although it is unclear what additional level of support
will be required. It is however envisaged that bulk supplies would continue to
be provided by Crosshouse pharmacy.
The clinical pharmacy service to the community hospital will require to utilise
joint premises with mental health pharmacy.
The range and volume of services, will dictate the wider dispensing needs
beyond mental health on the site and may require some resource transfer
from Crosshouse.
Corridors: Required features
•
•
•
Corridors should have no blind spots and allow maximum
observation;
Long unbroken corridors should be avoided, with the maximum use
of natural light and ventilation; and
Well signposted.
Mixed gender requirements
•
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
•
•
The design of the facility must comply with current legislation; and
The building should be sensitive to the needs of physical and sensory
disabled patients, staff and visitors.
Privacy and dignity requirements
•
The design of the unit must comply with current legislation
Number and types of rooms
107
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
•
The Pharmacy Department requires to have secure road access and
access point for deliveries.
Internal
•
The Pharmacy Department requires a central location for access to
both mental health and community hospital wards and also to
outpatient clinics.
Storage facilities
•
See under room detail description
Anticipated developments
Potential for further development of the area-wide clozapine service to
include near-patient testing/one stop dispensing – potentially within
outpatient facility.
108
Client Group Characteristics
Age and Gender
•
Not applicable
Admission Rates
•
Not applicable
Diagnoses
•
Not applicable
Anticipated illness-related behaviours
•
Not applicable
Anticipated clinical risks
•
Pharmacy staff will be appropriately trained in terms of violence and
aggression to minimise risk.
Patient dependency characteristics
Therapeutic Intent
Principal aims of clinical care
•
Clinical pharmacy services – providing pharmaceutical care to
patients in community hospital and mental health facility
Therapies
•
Not applicable
Therapeutic facilities required
Patient counselling room would require the following facilities:
•
IT access/telephone point
109
•
•
Secure doors to dispensary and waiting area (distinct from secure
staff entry to dispensary)
Panic alarm
Planned clinical meetings
•
Pharmacists will require appropriate accommodation to interview and
counsel patients (separately from the prescription counselling
service) and it would improve the current situation if outpatient
accommodation could be utilised for this purpose
Other Meetings
•
Pharmacy staff will attend relevant clinical and management
meetings as appropriate within NACH and offsite in relation to mental
health and community hospital services.
110
Appendix K - Tribunal/Meeting Area
Introduction and outline of services
Departmental Function
Recognising that the tribunal process will be difficult and confusing for some
patients and other parties, it is with this knowledge borne in mind that
venues must be provided which fully meet the user’s needs as well as
1
supporting the requirements of legislation contained within the Act .
That is to say that all venues must allow for hearings to be conducted in
privacy whilst allowing openness for sensitive discussions to take place.
There is also a requirement for patient/counsel discussion to take place
privately away from the main hearing room. Additionally, it must also be
acknowledged that some patients participating in hearings may require
taking some time out in a quiet area, becoming unwell or having to take
medication at some point during the proceedings.
Scope of Service/Specialist Services Provided
The accommodation is described in the section entitled Tribunal/Meeting
Area in the Schedule of Accommodation.
Model of Care
The Tribunal is a form of legal proceeding provided under mental health
legislation1 . Tribunal accommodation is required within both community and
in patient settings. The tribunal is a formal proceeding, chaired by officers of
the court, in attendance are solicitors, patients, advocate, family, Medical
and nursing staff caring for the patient and Mental Health officer who are
specialised social workers involved in the care of the patient
1
Mental Health (Care and treatment) (Scotland) Act 2003
111
Descriptive Overview
The purpose of the Tribunal Suite is to facilitate Tribunals in relation to the
Mental Health (Care and Treatment) (Scotland) Act 2003,
These will be crucial design considerations. –
•
•
•
The venue must meet all current legislation and regulations including;
heating, lighting, ventilation, access, sanitation, Health and Safety
and fire relating to the use or occupation of public access buildings.
It must be easily accessible to the public, staff and tribunal members
and not in an isolated or undesirable area. Reliable public transport
services should be in operation.
All accommodation must meet the requirements of the Disability
Discrimination Act 1995.
The Tribunal Suite and meeting area should promote safety, dignity, comfort
and privacy.
The area should:
•
•
•
•
•
•
•
Create a calm and restful atmosphere and an environment which is
non-threatening;
Be attractive, uplifting and interesting in terms of décor, fabric,
furnishings and interior and exterior design, as well as the use of
natural materials, colour and textures;
Create a feeling of well ventilated space, maximising the use of
natural light and minimising the reliance on artificial light;
Be sensitive to the needs of physically disabled patients, visitors and
staff;
Consider space and environment and recognise that this will be
important from both the external and internal perspective;
Adequate provision of telephone access and IT infrastructure will be
critical to effective communication, education and provision of
evidence-based practice; and
Allow a quiet environment with good level of confidentiality for legal
proceedings when those who are the subject of the tribunal can be
anxious, distressed or present behavioural problems.
•
Role and Function
•
The Tribunal fundamentally changes the way in which decisions will
be made on the care and treatment of people in Scotland who have a
mental health disorder. The Mental Health Tribunal for Scotland will
112
hear cases by means of a network of locally based tribunals across
Scotland.
•
Bed complement
•
No beds will be provided in this area
Planned patient activity
•
Inpatients will access this Tribunal Suite
General principles of operation
•
•
•
The three member tribunal panel plus clerk plus security staff arrive
at 9a.m;
The security presence is provided by the Tribunal and controls
access to the tribunal rooms and calls for those present to move from
the waiting area into the main hearing room; and
From 9am, the tribunal panel spend time reviewing papers in the
ante-room.
•
The tribunal hearing begin at 10a.m. in the main hearing room. In the
room will be:
•
•
•
•
•
•
3 member tribunal panel, plus tribunal clerk
the mental health officer making the application for detention
the responsible medical officer (consultant) for the patient
the patient (with or without a nurse escort)
patient’s family member(s) and or named person
patient’s legal representative and or advocacy worker
•
The panel hear the evidence submitted in the reports (2 medical, 1
MHO) and all three members can question the writers where
available to establish that criteria for detention and treatment are met.
•
The panel hears evidence from the patient and or their legal
representative, again all three members asking questions as
appropriate.
•
Having heard the evidence, the panel then retire to their ante-room to
consider their decision/ruling. While they do this, the other attendees
return to a waiting room.
•
All meet again in the main hearing room to hear the decision.
•
If the decision is that the patient is to be detained, they return/go to
an inpatient ward. At times this can require good patient
management, If the decision is that the patient is not detained, they
113
may go to a ward voluntarily or leave completely.
Design Synopsis
In addition to the core design synopsis/critical features, unique features to
this environment will be:
•
•
•
•
•
•
•
•
•
•
•
•
Intercom secure buzzer entrance;
Security will be provided at the least restrictive level, appropriate to
the patients needs;
The environment especially waiting areas requires to lend itself to
obtrusive and unobtrusive observation and in-keeping with Millan
Principles;
The environment must be pleasant, safe and the general ambience
should promote mental and physical health well being. Water should
be readily accessible;
There should be one single point of entry to the Tribunal Suite and
meeting area. Fire Egress routes can be planned but not for common
use or access;
Welcoming & homely;
Well ventilated and spacious;
Doors, locks and windows should be of a design which is antibarricade and enables access by staff in an emergency;
Maximum use of natural and artificial light;
Maximum use of natural and artificial ventilation;
Ligature points should be eliminated; and
Areas are non threatening and welcome.
Corridors: Required features
•
•
Corridor area should be kept to a minimum; and
Corridors should have no blind spots and allow maximum
observation.
Disabled access requirements
•
The design of the unit must comply with current legislation.
Privacy and dignity requirements
•
The design of the unit must comply with current legislation
114
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
•
Not applicable
Internal
•
The Tribunal Suite should be in close proximity to the inpatient mental
health wards – adjacent to the ambulance entrance.
Storage facilities
The following storage facilities are required for:
•
Store for documents/information leaflets relating to the Mental Health
(Care and Treatment) (Scotland) Act 2003, which will also be
displayed and available in the waiting areas
115
Anticipated developments
•
•
•
During the lifespan of the building a flexible approach to design will
be required which takes into account changing models in delivery of
care;
The building should be able to meet the needs of future Information
Technology developments; and
The building should be flexible in design to meet the challenges of an
ever changing and improving Health Service.
Client Group Characteristics
Age and Gender
•
16 years of age and upwards will access the Tribunal Suite
Admission Rates
•
The Tribunal Suite will be operational during working hours, MondayFriday 9-5pm
Diagnoses
•
Patients using the Tribunal Suite will have a varying range of mental
health problems/illness and may experience issues re drug/alcohol
misuse
Anticipated illness-related behaviours
•
•
•
•
•
•
•
•
Aggressive behaviour (verbal and physical);
Aimless or ritualistic behaviours;
Disinhibited behaviours;
Lack of personal risk awareness;
Suicide risk;
Unpredictable and impulsive behaviours;
Secondary physical disabilities/illnesses; and
Fear and apprehension.
116
Anticipated clinical risks
Clients who are attend to this department may be at risk from the following:
•
•
•
•
•
•
•
•
Deliberate self harm;
Harm to others;
Poor motivation;
Self neglect;
Suicidal intention;
Isolation in a community environment (social breakdown);
Institutionalisation; and
Displaying anxiety or range of other emotions.
Patient dependency characteristics
Therapeutic Intent
Principal aims of clinical care
•
There will be no direct clinical care taking place in the Tribunal
Suite/Meeting Area although the patient may be escorted and
observed by nursing staff.
Therapies
•
There will be no therapies taking place in the Tribunal Suite/Meeting
Area.
Therapeutic facilities required
•
There will be no therapy facilities required in the Tribunal
Suite/Meeting Area.
117
Planned clinical meetings
When the tribunal suite is not being used for a Tribunal the following
meetings could take place and will require:
•
•
•
•
•
•
•
•
•
Adequate space is required to provide for a variety of clinical
meetings which will take place on a daily basis;
Nursing handover reports;
Multi-disciplinary meetings;
Consultant meeting;
Junior Doctor reviews;
Care Programme Approach(CPA) meetings;
Case conferences;
1-1 clinical interventions; and
Adequate space to comply with Mental Health Act.
Other Meetings
•
When not used as a Tribunal Suite, general meetings and
recreational groups will access this area out with office hours or when
available.
Clinical risk management principles
•
Risk management for this client group is important. The environment
must be conducive to delivering the risk management plan
Operational Procedures
Working day plans
•
•
•
The Tribunal Suite will be accessible Monday – Friday, 9-5pm;
When this area is used for general meetings access will be obtained
by contacting the Mental Health Act administrator; and
These legal proceedings can be called with short notice and booking
would take precedence.
Staffing arrangements and shift patterns
•
Not applicable
Admission procedures
•
No admissions will take place in this area.
118
Record-keeping storage
•
No records will require to be stored in this area. Although documents
may required to be photocopied at short notice by the tribunal.
Visiting arrangements
•
Not applicable
Mealtimes/dining arrangements
•
Tribunals can be lengthy and it will be appropriate to provide tea and
coffee and water fountain facilities for tribunal members, patient and
other attendees to ensure hydration.
Laundry facilities and linen management
•
Not applicable
Functional content
Number of Inpatient Beds/Treatment Spaces
•
There will be no inpatient beds/treatment spaces in this area.
Investigative/Diagnostic/Treatment Capacity:
•
Not applicable
Outpatient Service (Number of Sessions and
specialist functions):
•
Currently outpatient tribunals take place in another tribunal suite
within the community in the main town of Irvine. It is unlikely this suite
will be used but would be a contingency if significant premises issues
made the other suite temporarily unavailable.
119
Specialist Technical Infrastructure Requirements
•
•
•
Experience suggests that access to telephone conferencing facilities
is helpful e.g. family member living at a distance or unable to travel;
Intercom buzzer entrance for late attendees and to prevent intrusion
to either waiting or tribunal areas; and
Access to FACE to allow Medical Staff to confirm information
requested by the panel members.
Projected Future Activity
Below is a breakdown of the number of hearings that have taken place from
April 2008 to March 2009. The future activity for the Tribunal Suite at North
Ayrshire Community Hospital will include all adult acute inpatients that are
currently provided for at Ailsa and Crosshouse Hospitals.
It is likely we may need to retain access to the current tribunal suite at Ailsa
for inpatient activity on the retained wards for Elderly Mental Health. These
numbers are very low and will have minimal impact on the projections below.
The Millan Suite, 49 Bank Street, Irvine premises will continue to be used for
community based patients and are organised by the Local Authority. This
1
required to be retained as guided by the ACT
Hearings
Venue
Ailsa Hospital
Crosshouse
Hospital
Millan Suite, 49
Bank St, Irvine
Total
April
2008
May
2008
June
2008
July
2008
Aug
2008
Sept
2008
Oct
2008
Nov
2008
Dec
2008
Jan
2009
Feb
2009
Mar
2009
10
10
9
10
8
10
5
7
9
11
13
15
117
4
6
3
4
5
6
2
3
0
1
3
5
42
0
0
3
3
1
2
4
2
3
1
0
0
19
14
16
15
17
14
18
11
12
12
13
16
20
178
Hearings
Male
Female
Total
Ailsa Hospital
67
50
117
Crosshouse Hospital
29
13
42
Millan Suite, 49 Bank St, Irvine
4
15
19
100
78
178
Venue
Total
120
Total
Key Relationships with Other Departments/NHS
Ayrshire and Arran /Social Services/Social
Work/Local Authority Services
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Solicitors/lawyers
Advocacy
Medical staff and nursing staff
Activities – shop, canteen.
Ambulance/clinical taxi transport for patients from other inpatient site
CAMHS – adolescent tribunals have a potential to be required.
Chaplaincy
Clinical taxis
Community Forensic Team
Hospital Social Work department
Internal support services – hotel services, portering, administration,
IT, communications,
Learning Disabilities clients very rarely may attend.
Local Authorities Social Services
Standby Social Work services
Voluntary sector
Close to
Adult Mental Health
inpatient wards
Reason
Patients access Tribunal
Suite
Category*
Desirable, Essential within
the inpatient building/new
build/OP extension.
Future Service Delivery Risks
•
•
•
•
It is anticipated that minor legislative changes to the Act will occur
and it is unlikely they will have a major impact on the Tribunal
function or suite;
Nationally the formality of Tribunals will be reviewed, national patient
groups have indicated the levels of stress experienced by patients is
too high and report it still feels ‘too like court’. Locally our existing
suite is highly regarded as being one of the best. It is desirable to
maintain and improve the facility being reprovided;
Nationally the number of tribunals taking place are higher than
desirable and a national review is expected with an aim to reduce
rates;
Out with this review, Local Activity levels could increase as it is
expected that the future models of care are expecting a high ratio of
detained patients to informal which could result in increased numbers
of tribunals. The suite will have the capacity to accommodate this but
121
•
the alterative use as a general meeting room function would diminish;
and
Future service demand is uncertain. This new provision needs to
reflect change in trends and be adaptable to future need.
122
Appendix L - Acute Mental Health Wards
Introduction and outline of services
Departmental Function
1
Teams and Links
Our Adult Mental Health Wards (AMH) are managed by nursing staff
working within a patient/person-centred, multi-disciplinary and multi-agency
framework in partnership with, physiotherapy, dietetics, occupational
therapy, speech & language therapy, advocacy, social work, advanced
nurse practitioners, psychology, medical staff and a range of visiting support
services. There are links with the Community Mental Health Teams and
where possible any other external agencies involved, prior to admission.
This involves the aforementioned parties being invited to Multi-Disciplinary
Meetings including Pre-Discharge Meetings. Further links exist with the
University of West of Scotland (Nurse Training) and the Royal College of
Psychiatrists (Medical Training).
At any given time there could be up to 6 nursing staff on duty (variable with
clinical demand) , this could be supplemented by up to 2 student nurses.
When the number of Medical (Consultants, Junior Doctors and Trainees),
Allied Health Professionals and representatives of other agencies are added
to this it is possible that up to 15 staff may be present and will require to be
accommodated on the ward at peak times.
2
As part of the “Hospital at Night Service”, the development of the Advanced
Nurse Practitioner role will provide cover at night which was previously
provided by junior medical staff.
Service Users
Although this is an adult admission area, both the accommodation and
delivery of care needs to be flexible enough to meet the needs of people of
all ages including Children under the age of 16 and those who may have a
physical disability and/or learning difficulties.
Patients will be admitted primarily as a result of a mental health problem
however they may also have physical symptoms, which may be due to a comorbidity of disease or because of dependence on drugs and/or alcohol.
123
3
The lifestyle choices made by some people with severe and enduring mental
illnesses may also lead to a lack of social skills and self neglect with a
subsequent and often significant deterioration in their state of physical
wellbeing.
During the patients stay they may be regularly visited by family, relatives and
friends who can also be involved in supporting the plan of care and
participate in the person’s recovery.
Therapies and Treatment.
The care team will assist the individual in taking an active role in their
recovery by providing a range of therapeutic activity/interventions.
Activity, supported by a comprehensive ongoing assessment, may be
scheduled or unscheduled, and will be co-ordinated and provided from a
multi-disciplinary perspective which will directly involve the patient/carer as a
key part of the team.
Activities will be designed to address a spectrum of health and social care
needs which typically include physical, psychological, recreational, life-skill,
cultural, spiritual and social elements.
Each person will be engaged with a care plan for each day of their stay,
which reflects their needs, wishes and aspirations and is cognisant of their
capabilities.
4
A key aim will be to provide a platform for social inclusion by re-integrating
the patient into the community and local services. Working towards
discharge will be the underpinning objective at all times to prevent
inappropriate lengths of stay and promote independence. Effective
integrated working and communication with community based health
services and other agencies will be a key service element.
Some individual therapies including patient consultations, psychological
therapies and advanced psychiatric assessments, will require private,
confidential space (significant sound insulation whilst not compromising
safety), allowing individuals the opportunity to express their emotions and
personal issues.
There will be access to Electro-Convulsive Therapy (ECT) twice weekly.
(more information on the ECT service is provided in the ECT/Minor
Procedures area section)
124
Space and Observation.
5
The feeling of space plays a key role in promoting recovery and, as such, it
is of the utmost importance that all patients have access to private and
communal space both internally, in the form of small quiet areas and
externally in the form of significant, safe therapeutic green space.
Some behaviours, for instance, behaviours associated with self harm, and
elevated mood may compromise the patient’s safety, increasing personal
risk. Therefore there is a need to have a high level of awareness/supervision
and observation of patients who are acutely unwell.
Legislation & Governance
We are governed by legislation which directs us to provide practical
solutions for patient safety and also the principles under the Mental Health
(Care and Treatment) (Scotland) Act 2003:
Non-discrimination - people with a mental disorder should, wherever
possible, retain the same rights and entitlements as those with other health
needs.
Equality - all powers under the Act should be exercised without any direct or
indirect discrimination on the grounds of physical disability, age, gender,
sexual orientation, language, religion or national, ethnic or social origin.
Respect for diversity - service users should receive care, treatment and
support in a manner that accords respect for their individual qualities,
abilities and diverse backgrounds and properly takes into account their age,
gender, sexual orientation, ethnic group and social, cultural and religious
background.
Reciprocity - where society imposes an obligation on an individual to
comply with a programme of treatment and care, it should impose a parallel
obligation on the health and social care authorities to provide safe and
appropriate services, including ongoing care following discharge from
compulsion.
Informal care - wherever possible care, treatment and support should be
provided to people with mental disorder without recourse to compulsion.
125
Participation - service users should be fully involved, to the extent
permitted by their individual capacity, in all aspects of their assessment,
care, treatment and support. Account should be taken of both past and
present wishes, so far as they can be ascertained. Service users should be
provided with all the information and support necessary to enable them to
participate fully. All such information should be provided in a way which
renders it most likely to be understood.
Respect for carers - those who provide care to service users on an
informal basis should receive respect for their role and experience, receive
appropriate information and advice, and have their views and needs taken
into account.
Least restrictive alternative - service users should be provided with any
necessary care, treatment and support both in the least invasive manner
and in the least restrictive manner and environment compatible with the
delivery of safe, effective care, taking account where appropriate of the
safety of others.
Benefit - any intervention under the Act should be likely to produce for the
service user a benefit which cannot reasonably be achieved other than by
the intervention.
Child welfare - the welfare of a child with mental disorder should be
paramount in any interventions imposed on the child under the Act.
Schedule of Accommodation
The accommodation is scheduled in Mental Health Services and is
described in the section entitled AMH Wards (Adult Mental Health) in the
Schedule of Accommodation.
Model of Care
The philosophy of care will be explicitly user focused and supported by a
robust systematic approach to clinical governance.
The objective of clinical services will be to provide a range of therapeutic
interventions which are planned, co-ordinated and provided from multidisciplinary and user/carer perspective, based on comprehensive ongoing
assessment. A key aim will be to provide a platform for social inclusion.
Of the individual and group activities available, some will be generic, some
126
specialised and some will be onsite and some offsite. Activities will be
designed to address a spectrum of health and social care needs which
typically include physical, psychological, recreational, life-skill, cultural,
spiritual and social elements.
Each person will be engaged with a programme of activity for each day of
their stay, which reflects their needs, wishes and aspirations and is
cognisant of their capabilities.
Working towards rehabilitation/discharge/recovery will be the underpinning
objective at all times, preventing inappropriate lengths of stay and promoting
independence and self reliance. Effective integrated working and
communication with community based health services and other agencies
will be a key service element.
Interventions will be evidenced-based or based on national consensus good
practice and will be under-pinned by national standards and clinical
guidelines.
The therapeutic environment will seek to fulfil the following functions:
•
•
•
•
•
•
•
A ward timetable that is consistent and which relates to the
organisation of time, space and patient activities;
The involvement of patients as active participants in their care,
contributing in a meaningful way to treatment decisions;
Provision of an environment conducive to the containment and
control of potentially dangerous behaviours through consistent staff
practices that assist patients to moderate their behaviour and develop
internal coping and control skills;
A culture of support in which staff actively promote a sense of hope,
well-being and self-esteem in their patients;
Recognise that the therapeutic environment and ambience of the
ward is a crucial element in how service users experience their inpatient stay and how they benefit from it and acknowledge that
therapeutic interventions, social and recreational activities all play a
part in the overall patient experience;
The validation and affirmation of each patient’s individuality
supported by a structure of person-centred and recovery focused
care planning
The therapeutic environment plays an important part in positive
treatment outcomes.
Descriptive Overview
The purpose of the inpatient service will be to provide an excellent standard
of well co-ordinated assessment, treatment and care, in a safe and
therapeutic setting for patients who are in the most acute and/or vulnerable
stage of their illness. Such patients will typically present with serious and
complex health and social care needs which cannot, at that time, be treated
and supported safely and appropriately at home or in an alternative, less
127
restrictive, residential environment.
The Unit utilises a Recovery approach to enable the individual to achieve
their maximum potential, which will include proactive discharge planning.
The inpatient service will be provided for 365 days, 7 days per week, 24
hours per day. The emphasis will be on the provision of a range of
interventions and treatment plans which patients experience as being safe,
humane and therapeutic. In this regard the inpatient facility will function as
an essential core component of a whole system approach to mental health
care in Ayrshire. Thereby, complimenting Primary Care Mental Health
Teams (PCMHT), Community Mental Health Teams (CMHT) and Crisis
Service. It is important that the new buildings and physical environment
reflect positive vision of mental health services as a normal part of health
service life and the life of the Ayrshire community they seek to serve.
The Royal College of Psychiatrist’s Report ‘Not just bricks and mortar’ &
‘Ten Standards for adult inpatient mental healthcare’
recommend the need for new, smaller, inpatient psychiatric units which must
reflect current practice and be of a standard likely to be acceptable to
st
patients and staff well into the middle of the 21 century.
The inpatient service should promote safety, dignity, comfort and privacy as
well as provide therapeutic opportunities for recovery and rehabilitation.
The care environment should:
•
•
•
•
•
•
•
•
•
•
Create a calm and restful atmosphere and an environment which is
non-threatening;
Maximise therapeutic opportunities and the ability to relieve boredom;
Afford no undue separation of staff from patients;
Be attractive, uplifting and interesting in terms of décor, fabric,
furnishings and interior and exterior design, as well as the use of
natural materials, colour and textures;
Create a feeling of well ventilated space, maximising the use of
natural light and minimising the reliance on artificial light;
Provide opportunities for exercise, leisure and education;
Be sensitive to the needs of physically disabled patients, visitors and
staff;
Consider space and environment and recognise that this will be
important from both the external and internal perspective;
Be imaginative and creative use of space will be vital, for example,
the avoidance of long corridors and the creation of attractive easily
maintained/accessed landscaped gardens;
It is essential for the service to be flexible to the changing needs of
individuals and groups e.g. changes in conditions, gender, numbers,
128
•
•
•
•
•
cultural needs etc. The physical environment will require to be
responsive to such changes in demand;
Individual bedrooms with en-suite facilities will be required for all
patients to maximise opportunity for privacy and dignity;
All therapeutic rooms should be designed to enable speech privacy;
Adequate provision of telephone access and IT infrastructure will be
critical to effective communication, education and provision of
evidence-based practice;
Dining arrangements for patients and adequate storage space for
equipment and personal belongings will require careful thought to
ensure adequacy and suitability for purpose; and
Garden areas should be designed to provide contrasting textures and
colours of plants, providing sensory stimulation and promoting sense
of calm and relaxation. There should also be sheltered areas,
suntraps and comfortable seating within the overall design.
Role and Function
Care will be patient centred:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Psychiatric in-patient admission and assessment wards in single
room accommodation;
Services must respect the individual and recognise their full rights
and responsibilities as a citizen;
There will be a focus on clinical and environmental safety and
security for the patient, general public and staff within the service;
Services must balance the need for safety and security with the
provision of a therapeutic environment;
Security and observation will be provided at the least restrictive level,
appropriate to the patients needs;
Security will be provided by a range of approaches including:
Informed clinical judgement, risk assessment, appropriate levels of
staff, safe systems of work, environmental and physical security;
The environment requires to lend itself to obtrusive and unobtrusive
observation and in-keeping with Millan Principles;
Environment needs to afford an opportunity to observe acutely unwell
patients, but also facilitate privacy and dignity;
The environment must be pleasant, safe and the general ambience
promotes mental and physical health well being;
The unit will be state-of-the-art offering modern, ground-breaking
acute adult mental health inpatient facilities for the population NHS
Ayrshire & Arran;
It will continue to work closely and link with the community
infrastructure;
It will focus on discharge planning and minimal period of stay inkeeping with the shift in the balance of care;
Patients will have access to information on the service and their care
package, which will promote the greatest degree of selfdetermination, informed choice and equity;
Provide innovative, evidence based treatment and care to individuals
129
•
•
and their families underpinned by a strong values base;
Aligned with National drivers for example: QIS standards, ICP’s and
‘Acute Care Framework’ ; and
Each person will be seen as and treated as an individual.
Bed complement
•
•
•
•
60 beds over 3 wards
Provided in single room accommodation with en-suite facilities;
Each ward will be mixed sex but with flexibility to react to pressures of
male/female demand;
The service should be able to be developed and afford flexibility of
beds for future potential service trends and changes; and
•
Planned patient activity
Admissions will be via Bed Managers from a variety of sources such as:
•
•
•
•
•
•
•
•
Community Teams (Generic and Crisis)
Intensive Psychiatric Care Unit (step down)
Prisons
Accident and Emergency
Direct GP referral
Outpatients
Neighbouring NHS boards in time of crisis
Primary Care Teams
Usual admissions to this area will represent clients who:
•
•
•
Require assessment and treatment for an acute phase of their illness
or who require assessment of their mental state
Present risks that mean they are no longer able to be managed safely
by Community Services
Are subject to legislation that requires them to be admitted to hospital
for assessment/treatment
130
General principles of operation
•
•
•
•
•
•
•
•
All clinical, therapeutic and social care will be provided at the least
restrictive level appropriate to the needs of the client group;
Invasive clinical interventions such as restraint and rapid
tranquilisation will be undertaken in a safe, non stimulating
environment that respects the individual’s privacy and dignity;
Based on Millan Principles;
Recovery focussed;
10 Essential Shared Capabilities (ESC)/Values Based Approach ;
Multi-disciplinary approach;
Clinical interventions will be evidence based and reflect current best
practice; and
Intervention will be provided in keeping with an individual’s care plan
utilising a person centred approach.
Design Synopsis
In addition to the core design synopsis/critical features, unique features to
this environment will be:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
The layout of wards should allow for discreet groupings i.e. hotel
services, clinical & treatment, bedrooms;
There should be one single point of entry to the ward;
Welcoming & homely;
Well ventilated and spacious;
Doors, locks and windows should be of a design which is antibarricade and enables access by staff in an emergency;
Maximum use of natural and artificial light;
Maximum use of natural and artificial ventilation;
Discreet hotel and storage services;
Dining facilities that enhance the meal experience;
Clinical areas that are non threatening and welcoming;
Bedroom areas should enhance the therapeutic experience and also
provide privacy;
All public areas within the ward should be easily observable with no
blind spots;
There should be one single point of entry to each ward
Ligature points should be eliminated;
As per smoking policy, outdoor smoking areas should be available &
suitable for all seasons/weather conditions;
All single rooms need to be observed by a nurses station which could
be manned 24/7;
All areas including bedrooms should be spacious, preventing those
using our service feeling enclosed;
Emphasis will be on day activity, engagement & treatments so
sufficient space in day areas for 1-1 therapy and group work, not bed
space; and
There will be flexibility in approximately 10% of beds without
131
compromising mixed sex guidelines.
Corridors: Required features
•
•
•
•
•
Corridor area should be kept to a minimum;
Corridors should have no blind spots and allow maximum
observation;
Where corridors are not just to get from A to B they could have the
opportunity for informal social contact, non institutional and natural
light; and
Corridors should provide seated areas for quiet contemplation.
Mixed gender requirements
•
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
•
The design of the unit must comply with current legislation
Privacy and dignity requirements
•
The design of the unit must comply with current legislation
132
Number and types of rooms
•
•
•
•
60 single, en-suite bedrooms with rooms configured into 3 wards
Each ward will have 2 wings
Waiting/Visiting area to be provided at the entrance to the ward
2 High Observation rooms per unit
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
•
•
•
•
•
•
•
The wards should be adjacent to each other and connected by a
common hub area
Adult wards and IPCU grouped in close proximity to one another,
allowing access to support cluster 1 and café area without going
outside
All should have access to discreet external and landscaped space
that is designated specifically to each ward
The units should have access to private communal safe, stimulating
and landscaped and sheltered garden areas
Close proximity to support cluster 1
Co-located with ECT suite, IPCU, medical staffing, bed manager,
gardening facilities, operational management staff, recreational
facilities
Should be in close proximity to the Tribunal Suite/Meeting Area
Internal
•
•
•
•
•
•
•
•
Dining and day activities should be close to the entrance of the units
and distant to the bedrooms
Clean and dirty utility and linen room should be away from the main
clinical areas
Distressed patient (calming room) to be at the entrance to the
bedroom area to ensure use both/day night in a quieter area
The bedrooms should be distant from the clean and dirty utility room,
linen room, reception/interview room, charge nurse office and dining
room
The Charge Nurses office should be at the main unit entrance
The touchdown bases should be at the area of highest observation
Store rooms, linen room, clean and dirty utility rooms, cleaners
housekeeping room, WC should be clustered together and prevent
access by non-clinical staff. This should be away from clinical area
and bedrooms, and shared by the unit
Patient’s laundry should be distant to the bedrooms,
reception/interview rooms and multi-disciplinary room.
133
•
•
•
•
•
Reception/Interview room, Charge Nurse office and multidisciplinary
room (Clinical Area) should be clustered together and distant from the
bedrooms and hotel services area.
Clean Utility should be close to the duty room
The bedrooms should be distant from the hotel services and clinical
areas.
The sitting rooms should be sited in accordance with the mixed sex
guidance.
The social/activity/therapy area, sitting room and pantry should be
sited in such a way that allows ease of access and use but distant
from the hotel services area and dining room
Storage facilities
The following storage facilities are required for:
•
•
•
•
•
•
•
•
•
Access to equipment store for all units as required
Flat linen and towels
Miscellaneous items
Mobility aids as required
Range of seasonal equipment (eg Christmas decorations)
Spare duvets, pillows & mattresses
Therapeutic equipment
Secure lockers in each bed area
Activities store
Anticipated developments
•
•
•
During the lifespan of the building a flexible approach to design will
be required which takes into account changing models in delivery of
care
The building should be able to meet the needs of future Information
Technology developments
The building should be flexible in design to meet the challenges of an
ever changing and improving Health Service
Client Group Characteristics
Age and Gender
•
Ideally 16 - 64 years male and female, some discretion at either end
re Child and Adolescent mental health services (CAMHS) patients
and those of an older age who may still have contact with ‘adult’
services
Admission Rates
•
Admissions are accepted 365 days a year, 24 hours a day
134
Diagnoses
•
Patients admitted to the facility will have a varying range of mental
health problems/illness and may experience issues re drug/alcohol
misuse
Anticipated illness-related behaviours
•
•
•
•
•
•
•
•
•
Aggressive behaviour (verbal and physical)
Aimless or ritualistic behaviours
Disinhibited behaviours
Lack of personal risk awareness
Self Harm behaviours
Suicide risk
Unpredictable and impulsive behaviours
Secondary physical disabilities/illnesses
Fear and apprehension
Anticipated clinical risks
Clients who are admitted to this ward may be at risk from the following:
•
•
•
•
•
•
•
Deliberate self harm
Harm to others
Poor motivation
Self neglect
Suicidal intention
Isolation in a community environment (social breakdown)
Institutionalisation
Patient dependency characteristics
Therapeutic Intent
Principal aims of clinical care
Inpatient care is one element of the care pathway. It offers time limited
safety, support and therapy to people who are too unwell to be cared for in a
non hospital setting. It is to improve the person’s mental and physical health
and functioning.
Usual admissions to these areas will represent clients who:
•
•
•
•
Are deemed to be in crisis/vulnerable
Require high levels of observation/intervention
Require a place of safety for a short period
Are at risk of harm to self or others
135
•
•
•
•
•
•
•
•
•
•
•
Are at risk of severe neglect
Behave in such a way that cannot be managed in other care settings
Are at risk of suicide
Who require short term mental health assessment and treatment
Who require admission under the terms of the Mental Health Act
To provide individualised care to people who are experiencing mental
illness or distress who require in-patient care
To assist individuals to improve their mental and physical health and
functioning and social interaction.
Maximising person’s level of independence
To provide a recovery based approach to care
Should be underpinned by the Millan Principles and the 10 Essential
Shared Capabilities (ESC’s)
Inpatient care is one element of the care pathway. It offers time
limited safety, support and therapy to people who are too unwell to be
cared for in a non hospital setting. It is to improve the person’s mental
and physical health and functioning
Therapies
•
•
•
•
•
Individual and group therapies will be provided in an appropriate
setting within and out with the facility in accordance with an
individualised care plan. On a planned and ad hoc basis
Therapies will enhance the care experience and will be focussed
upon specific agreed interventions and outcomes
Therapy should be in keeping with recovery/Tidal Model and should
be evidence based
Therapies should be provided by a wide range of multi disciplinary
staff
Therapy Examples – Anger management, Coping Skills, Anxiety
management, ‘talking therapies’ & engagement
Therapeutic facilities required
•
•
Adequate space to provide therapeutic interventions as required
within the units both as groups and 1-1
Adequate storage space to contain therapeutic equipment will be
required within the units
Planned clinical meetings
•
•
•
•
•
•
•
•
•
Adequate space is required to provide for a variety of clinical
meetings which will take place on a daily basis
Nursing handover reports
Multi-disciplinary meetings
Consultant meeting
Junior Doctor reviews
Care Programme Approach(CPA) meetings
Case conferences
1-1 clinical interventions
Adequate space to comply with Mental Health Act
136
Other Meetings
•
•
•
•
•
•
•
Appraisal/supervision meetings
Educational meetings
Meetings with extended care team
Meetings with relatives
Team meetings
Ward community meeting
Group activities
Clinical risk management principles
•
•
•
•
•
Risk management for this patient group is important. The
environment must be conducive to delivering the risk management
plan
Based on a proactive approach to positive risk management
(embedded within the service)
Formalised assessment tools will be utilised and process reviewed on
an ongoing individualised basis
On admission each patient is assessed in accordance with a
recognised risk assessment tool
Based on this initial risk management plan is developed which will
also determine the person’ observation status
Operational Procedures
Working day plans
•
The unit will be open 365 days per year and 24 hours per day
Staffing arrangements and shift patterns
•
•
•
Multidisciplinary team handovers will take place at set times
throughout the day as determined by the ward team.
The unit will be staffed 365 days per year and 24 hours per day
Staffing levels and shift patterns will be set out to achieve the
optimum level of therapeutic care in a safe and secure setting
Admission procedures
•
•
Admissions will be on an as required basis, criteria/process to be
refined by the new model of care
Admissions are accepted anytime
Record-keeping storage
•
All clinical case records require to be stored within a lockable cabinet
within a lockable room
137
•
Items of secure stationery require to be stored within a lockable
cabinet
Visiting arrangements
•
•
Visiting arrangements will be as agreed with the unit team and may
take place within the visitors room, dining room.
If the patient’s condition allows, visitors can take them to the café
area in the main entrance or out with the unit area
Mealtimes/dining arrangements
•
•
•
Facilities must promote the ambiance of the meal experience.
Dining will be ward based and there will be three mealtimes per day
Facilities must be available to permit the consumption of hot and cold
drinks outwith recognised mealtimes
Laundry facilities and linen management
•
•
A laundry room is required to provide for personal washing, drying
and ironing of personal clothes
Bed linen etc will be uplifted and sent to area laundry(discreet
entry/exit)
Functional content
Number of Inpatient Beds/Treatment Spaces
•
•
60 single, en-suite bedrooms configured into 3 wards each with 2 x
10 bedded wings
Comprising of two wings per unit for gender split
Investigative/Diagnostic/Treatment Capacity:
•
•
Will require to be accessed at nearest General Hospital and other
specialist services as required
Access to ECT
Outpatient Service (Number of Sessions and
specialist functions):
•
Not applicable
138
Specialist Technical Infrastructure Requirements
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Personal alarms
Wall mounted alarms
Nurse Call System
Slow Door Systems (commended by MWC)
Emergency Response Team (2222)
Portable oxygen cylinders.
Secure Entry System out of hours – intercom at entrance to wards.
Telephones for internal and external communications.
Mobile phones for escort duties
Emergency Response Pack
ECG machine
Emergency Medication Box for escort duties
Ward Safe
All wards should be wireless enabled
Patients should have access to internet based services in all clinical
areas of the new hospital.
Clinical meeting rooms should have access networked Pc’s and to
either large plasma screens or to projectors to facilitate team
discussion of cases in clinical reviews of care.
Smartboard technology could be used to facilitate replacements for
whiteboards to manage bed states etc in ward areas. They should be
connected to network pc’s and bed management systems when they
are available via new Patient Management systems.
Meeting rooms could have access to teleconference facilities to
facilitate multi-agency working and access to meetings for staff in
rural and island areas.
All clinical and admin staff use a PC on a daily basis, they will require
access to networked PC’s to carry out their duties.
Projected Future Activity
Key Relationships with Other Departments/NHS
Ayrshire and Arran /Social Services/Social
Work/Local Authority Services
•
•
•
•
•
•
•
•
•
•
•
Activities – shop, canteen, hair salon, gym
Advocacy
All services – General Hospital
Ambulance
Bed Managers
CAMHS
Chaplaincy
Child protection
Childcare services
Clinical taxis
Community Mental Health Teams
139
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
CRISIS Teams
Complementary therapies
Dental services
Education and universities
Forensic Team
GPs
Hospital Social Work department
Internal support services – hotel services, portering, administration,
IT, communications, finance, estates
Learning Disabilities
Local Authorities Social Services, housing, benefits agency, tenancy
support, job centre plus, citizens advice service, pet fostering etc
Medical staff
Others Allied Health Professionals
Pharmacy
Police
Psychology
Service user groups/carer groups
Solicitors/lawyers
Standby Social Work services
Voluntary sector
Close to
IPCU
•
Tribunal Suite
•
•
•
•
•
•
•
Recreational Activities
•
Junior Staff on-call
accommodation
•
ECT
•
•
•
•
•
•
Reason
Ease of transfer of
patients
Safety
Staff assistance
Patients privacy
Ease of access for
inpatients
Safety
Staff assistance
Accessible
for
visiting agencies
Ease of access to
garden area
Immediate
response – 24/7
Safety
Ease of access for
inpatients
Safety
Staff assistance
Accessible
for
visiting agencies
Accessible
for
emergency
response
Category*
Essential
Desirable
Desirable
Important
Desirable
140
Future Service Delivery Risks
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Changes in practice
Changes in diagnostic pattern for admission eg personality disorders,
challenging behaviour, Autistic Spectrum Disorder (ASD), brain injury,
Alcohol Related Brain Damage (ARBD) and changes in diagnostic
pattern for admission
New Crisis service – unclear impact on bed need
Ageing population – more elderly patients
Demographic changes
Integrated Care Pathways (ICP)
HEAT targets – readmission rates, suicide prevention etc
Positive risk taking
Other services developing
Bed availability and bed blocking due to the lack of alternative
community provision
Activity levels unpredictable
Future service demand is uncertain. This new provision needs to
reflect change in trends and be adaptable to future need
Service Level Agreements (SLA) out of area no longer available for
extra-contractual referrals therefore service would again have to
adapt to that need
All adult inpatient beds are now housed on one site, therefore
contingency plans need to be considered in case of emergencies
Accessibility to single site option
141
Appendix M - Intensive Psychiatric Care Unit
(IPCU)
Introduction and outline of services
Departmental Function
1
Teams and Links
Our Intensive Psychiatric Care Unit (IPCU) is managed by nursing staff
working within a patient/person-centred, multi-disciplinary and multi-agency
framework in partnership with, physiotherapy, dietetics, occupational
therapy, speech & language therapy, advocacy, social work, psychology,
medical staff and a range of visiting support services. Strong working links
are maintained with the Adult Admission Wards.
In addition assessment and treatment is undertaken for the Courts, under
assessment or treatment orders.
2
At any given time there could be up to 6 nursing staff on duty (variable with
clinical demand), this could be supplemented by up to 2 student nurses.
When the number of Medical (Consultants, Junior Doctors and Trainees),
Allied Health Professionals and representatives of other agencies are added
to this it is possible that up to 14 staff may be present and will require to be
accommodated on the ward at peak times.
Service Users
The accommodation and delivery of care needs to be flexible enough meet
the needs of people of all ages and those who may have a physical disability
and/or learning difficulties.
IPCU provides assessment and care for:
A) patients suffering from an acute psychiatric illness, the nature and
degree of which is such that, in the interest of their own health and
safety and/or for the protection of others, they require intensive
nursing care in a secure ward setting, which cannot be provided in
other acute mental health wards. Because of the above they may
require to be detained under the terms of the Mental Health (care
and Treatment) (Scotland) Act 2003.
142
B) Suspected mentally disordered offenders remanded by the Courts
under the Criminal Procedures Act (1995) and who, because of their
propensity for aggressive behaviour, cannot be adequately managed
within other acute mental health wards
Patients will be admitted primarily as a result of a mental health problem that
requires that they be nursed in a secure setting, however they may also
have physical symptoms, which may be due to a co-morbidity of disease or
because of dependence on drugs and/or alcohol.
3
The lifestyle choices made by some people with severe and enduring mental
illnesses may also lead to a lack of social skills and self neglect with a
subsequent and often significant deterioration in their state of physical
wellbeing.
During the patients stay they may be regularly visited by family, relatives and
friends who can also be involved in supporting the plan of care and
participate in the person’s recovery.
Therapies and Treatment
The care team will assist the individual in taking an active role in their
recovery by providing a range of therapeutic activity/interventions.
Activity, supported by a comprehensive ongoing assessment, may be
scheduled or unscheduled, and will be co-ordinated and provided from a
multi-disciplinary perspective which will encourage involvement of the
patient/carer as a key part of the team.
Activities will be designed to address a spectrum of health and social care
needs which typically include physical, psychological, recreational, life-skill,
cultural, spiritual and social elements.
Each person will be engaged with a care plan for each day of their stay,
which reflects their needs, wishes and aspirations and is cognisant of their
capabilities with due regard to any requirement for enhanced safety and
security.
The service is recovery focussed, it provides intensive treatment and
interventions to patients who present an increased level of clinical risk and
require an increased level of observation and security.
Working towards transfer to a less secure setting will be an underpinning
143
objective at all times to prevent inappropriate lengths of stay in IPCU
4
IPCU aims to provide a conducive therapeutic environment in which
patient’s illnesses can be assessed and treated and thereby improve their
psychological (and physical) well being; control their aggression and reduce
the risk of self harm. This is generally to ensure that further management
can be carried out in a lesser secure ward setting. Many people with severe
mental health problems still require intensive secure hospital treatment
when they are most unwell.
•
5
•
Some individual therapies including patient consultations,
psychological therapies and advanced psychiatric assessments, will
require private, confidential space (significant sound insulation whilst
not compromising safety), allowing individuals the opportunity to
express their emotions and personal issues.
Space and Observation
The feeling of space plays a key role in reducing levels of anxiety and
aggression and promoting recovery and, as such, it is of the utmost
importance that all patients have access to private and communal space
both internally, in the form of small quiet areas and externally in the form of
significant, safe, secure therapeutic green space. Where patients are unable
to leave a ward area as a result of their illness/behaviours the provision of
space is increasingly important in promoting recovery.
•
Some behaviours, for instance, behaviours associated with self harm
and elevated mood may compromise the patient’s safety, increasing
personal risk. Therefore there is a need to have a high level of
awareness/supervision and observation of patients in IPCU at all
times.
Legislation & Governance
We are governed by legislation which directs us to provide practical
solutions for patient safety and also the principles under the Mental Health
(Care and Treatment) (Scotland) Act 2003:
Non-discrimination - people with a mental disorder should, wherever
possible, retain the same rights and entitlements as those with other health
needs.
Equality - all powers under the Act should be exercised without any direct or
indirect discrimination on the grounds of physical disability, age, gender,
sexual orientation, language, religion or national, ethnic or social origin.
Respect for diversity - service users should receive care, treatment and
support in a manner that accords respect for their individual qualities,
144
abilities and diverse backgrounds and properly takes into account their age,
gender, sexual orientation, ethnic group and social, cultural and religious
background.
Reciprocity - where society imposes an obligation on an individual to
comply with a programme of treatment and care, it should impose a parallel
obligation on the health and social care authorities to provide safe and
appropriate services, including ongoing care following discharge from
compulsion.
Informal care - wherever possible care, treatment and support should be
provided to people with mental disorder without recourse to compulsion.
Participation - service users should be fully involved, to the extent
permitted by their individual capacity, in all aspects of their assessment,
care, treatment and support. Account should be taken of both past and
present wishes, so far as they can be ascertained. Service users should be
provided with all the information and support necessary to enable them to
participate fully. All such information should be provided in a way which
renders it most likely to be understood.
Respect for carers - those who provide care to service users on an
informal basis should receive respect for their role and experience, receive
appropriate information and advice, and have their views and needs taken
into account.
Least restrictive alternative - service users should be provided with any
necessary care, treatment and support both in the least invasive manner
and in the least restrictive manner and environment compatible with the
delivery of safe, effective care, taking account where appropriate of the
safety of others.
Benefit - any intervention under the Act should be likely to produce for the
service user a benefit which cannot reasonably be achieved other than by
the intervention.
Child welfare - the welfare of a child with mental disorder should be
paramount in any interventions imposed on the child under the Act.
Schedule of Accommodation
The accommodation is scheduled in Mental Health Services and is
described in the section entitled IPCU in the Schedule of Accommodation.
145
Model of Care
Descriptive Overview
The Intensive Psychiatric Care Unit has a clear and defined role in providing
support to the local General Adult Wards and Forensic Services. The
patients may have more complex and challenging illnesses and behaviours
than those in General Psychiatric Wards, some of these may manifest
themselves in increased levels of violence and aggression.
The ward environment needs to be conducive to enabling greater
observation and control of patients than exists within the adult admission
wards.
The ‘special care area’ within the ward will be used for particularly disturbed
and aggressive patients requiring at times a non stimulating environment
away from the main ward area and the overall environment within the ward
should be conducive to providing care within a safe setting. This area should
be en-suite to one bedroom and distant to day facilities.
The design should meet the national standards for an IPCU and in
accordance with the NHS design audit tool.
The aim of the IPCU is to deliver the right care, at the right time, to the right
patient. These aims should be delivered through a system of:
• Needs assessment
• Risk assessment
• Risk management
• Treatment planning and delivery
Each of these processes is conducted as part of a structure or system in
order to realise a number of benefits including:
• All of the multi disciplinary team caring for the patient, the patient
themselves and their carers should be able to share information regarding
the identified needs, risks, objectives, interventions and treatments.
• Each should understand decisions that are being made and have
reasonable expectations of what should be delivered and when
• The multidisciplinary team should be able to use the assessment and
planning structure to avoid duplication in their work, identify any gaps and
to prioritise the interventions, treatment and support they provide
146
Role and Function
IPCU is a ward whose function will be to essentially provide assessment,
treatment and care for people who:• Suffer from acute psychiatric illnesses, the nature and degree of which is
such that they require intensive nursing care in a secure ward setting, in
the interest of their own health and safety, and/or for the protection of
others.
• Because of the above, they may require to be detained in hospital under
the terms of the Mental Health (Care & Treatment) (Scotland) Act 2003.
• Are suspected mentally disordered offenders remanded by the courts
under the Criminal Procedures Act 1995 and who because of their
propensity for aggressive behaviour, cannot be adequately managed
within the ordinary acute psychiatric ward setting, or are restricted due to
being remanded back to hospital, therefore requiring a secure IPCU
• IPCU will operate with a consultant-led multi-disciplinary team of medical,
nursing and other AHP (allied health professionals) staff.
• It is expected that the expertise of AHP staff like Psychology, Occupational
Therapy and Physiotherapy can be called upon.
• Clinical responsibility for all patients, during their stay on the ward will
primarily be that of the Ward Consultant and Nurse in Charge
• IPCU will work in close co-operation with the source of referral at all times.
• Care will be patient centred with their privacy and dignity being preserved
at all times.
• The service must balance the need for safety and security with the
provision of a therapeutic environment.
• The service must respect the individual.
Bed complement
147
• 8 beds provided in single room accommodation with en-suite facilities
• Special Care Area to comprise of sitting area, bedroom, WC and shower
• Bed provision will be in accordance with the mixed sex guidelines
Referral sources and reasons
Admissions will be accepted from a variety of sources such as:
• Prison services (short term assessment)
• Court services (short term assessment)
• Other secure hospitals
• Admission wards
• Continuing care wards
Usual admissions to this area will represent patients who cannot be safely
managed in an open acute ward environment by virtue of:
• Requiring high levels of prolonged observation and high nurse patient ratio
• Presenting significant risk of harm to others
• Requiring to be in hospital as part of their compulsion under the terms of
the Mental Health Act or Criminal procedures Act.
General principles of operation
• Millan Principles
• Recovery focussed
• Collaborative
• 10 Essential Shared Capabilities / Values Based Approach
• Multi-disciplinary approach
• Clinical interventions will be evidence based and reflect current best
practice
• Intervention will be provided in keeping with an individual’s care plan
utilising a person centred approach
• Emphasis on day activity & engagement in broad range of social &
therapeutic activities to support physical & mental wellbeing
148
Design Synopsis
In addition to the core design synopsis/critical features, unique features to
this environment will be;
• In keeping with IPCU Standards
• Doors, locks and windows should be of a design which is anti-barricade
and enables access by staff in an emergency situation
• Maximum use of natural and artificial light
• Maximum use of natural and artificial ventilation
• Discreet hotel and storage services
• Dining facilities that enhance the meal experience
• Clinical areas that are non threatening and welcoming
• Bedroom areas should enhance the therapeutic experience and also
provide privacy at night
• There will need to be flexibility in approximately 10% of beds without
compromising mixed sex guidelines
• All areas within the ward should be completely observable with no blind
spots
• Ligature points should be eliminated
• As per smoking policy, outdoor smoking areas should be available for all
seasons.
• Doorways should be wide enough to allow ease of access for a patient
under physical restraint.
• Air Lock entrance to ward (Reception/Waiting area)
• Calming features built into the fabric of the building
• All bedrooms need to be observed by the staff base: 3 staff at night but
could be manned 24/7
• The environment requires to lend itself to obtrusive and unobtrusive
observation
• There will be an Special Care Area which will be a discrete, self contained
living space, where those very disturbed patients, who are also very
disturbing and disruptive to other patients, can be safely, humanely and
effectively nursed separated from the rest of the ward. Almost like a mini
apartment.
This area should be:
• Discrete, lockable and to one end of the ward to minimise noise
disturbance
• Self contained which contains living/day room, bedroom and
toilet/shower
• Safe with minimum furniture made from pre-cast foam
149
• Capable of having two staff in attendance at all times
• Designed to allow for the activities of daily living to be maintained in
a humane environment
• Non stimulating
Corridors: Required features
• Corridors should have no blind spots and allow maximum observation
• Long unbroken corridors should be avoided, with the maximum use of
natural light and ventilation.
• Corridors should be kept to a minimum.
Mixed gender requirements
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
The design of the facility must comply with current legislation
The building should be sensitive to the needs of physical and sensory
disabled patients, staff and visitors.
Privacy and dignity requirements
The design of the unit must comply with current legislation
150
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
• The IPCU should be adjacent to the Acute Mental Health Wards and be
connected by a common hub area
• The IPCU should have access to private safe, stimulating and landscaped
garden areas
• Close proximity to Support Cluster 1
• Sheltered smoking area outside
• Close proximity to consultation and interventional area/outpatients
department
• Car parking area
Internal
• The Duty Room should be in an area of high observation within the ward
• The open plan dining room and pantry should be close to the entrance of
the ward and distant to the bedrooms
• Store room, linen room, clean and dirty room, cleaners’ housekeeping
room and staff WC should be clustered together and prevent access by
non-clinical staff. This should be away from the clinical area and
bedrooms.
• Patient’s laundry should be distant to the bedrooms, interview rooms and
multi-disciplinary room.
• Interview
rooms,
charge
nurse
office
and
fitness
suite,
social/activity/therapy area should be clustered together and distant from
the bedrooms and hotel services area.
• Clean utility/treatment room should be close to the staff base for 3 staff
• The bedrooms should be distant from the hotel services and clinical areas.
• The sitting room should be sited in accordance with the mixed sex
guidance.
• The social/activity/therapy area, sitting room and pantry should be sited in
151
such a way that allows ease of access and use
• The special care area should be distant to the hotel services, clinical areas
Storage facilities
The following storage facilities are required for:
• Specialist bathroom with suitable lifting aid (portable)
• Secure lockers x 8 in personal goods store for patient personal
possessions that are not stored in their own room
• Flat linen and towels
• Spare duvets and pillows
• Activities store
• Storage room for miscellaneous items (quite large)
• Range of seasonal equipment (eg. Christmas decorations)
Anticipated developments
• The building should be flexible in design to meet the challenges of an ever
changing and improving Health Service.
• The building should be able to meet the needs of future Information
Technology developments
152
Patient Group Characteristics
Age and Gender
• 16 to 65 years old although sometimes exceptional circumstances will lead
to some flexibility.
• Male and Female
Admission Rates
• Admissions are accepted 365 days per year, 24 hours per day.
Diagnoses
Patients admitted to the ward will have a varying range of mental illness
diagnosis.
Anticipated illness-related behaviours
• Aggressive behaviour (verbal and physical)
• Aimless or ritualistic behaviours
• Disinhibited behaviours
• Lack of personal risk awareness
• Suicide risk
• Unpredictable and impulsive behaviours
• Secondary physical disabilities/illnesses
• Fear and apprehension
• Patients in an IPCU are more likely to have complex needs, including
resistant psychotic illness, disadvantaged socioeconomic background and
co-morbid substance abuse problems, compared with the patient
population of general adult mental health services
• Serious assaultative behaviour
Anticipated clinical risks
Patients who are admitted to this ward will be at an increased risk from the
following:
• Absconding with associated risks
153
• Deliberate self harm
• Harm to others
• Self neglect
• Challenging behaviour
• Suicidal intention
• Disinhibited behaviour
Patient dependency characteristics
Therapeutic Intent
Principal aims of clinical care
• IPCU care is one element of the care pathway. It offers time limited safety,
support and therapy to people in a secure environment who are too unwell
to be cared for in open wards
• Is to improve the person’s mental and physical health and functioning.
• Getting people well enough to return to main stream services, for instance,
more open wards
• Completing assessments and appropriate transfer of patients
• Should be underpinned by Milan Principals and 10 ESC
• All clinical, therapeutic and social care will be provided at the least
restrictive level appropriate to the needs of the patient group.
• Clinical interventions will be evidence based and reflect current best
practice.
• Invasive clinical interventions will be undertaken in a safe, non stimulating
environment that respects the individuals privacy and dignity
• The IPCU is not to be respite from other elements of the care pathway
The IPCU will provide a stepping stone to inclusion, not a departure point for
exclusion
Therapies
• Individual and group therapies will be provided within the facility in keeping
with the care plan and models of care.
• Therapies should be in keeping with recovery/tidal model and be
evidenced based
• Therapies will enhance the care experience and will be focussed upon
154
specific interventions and outcomes
Therapies should be provided by a wide range of multi-disciplinary staff
Therapeutic facilities required
• Adequate space throughout the day to provide therapeutic interventions as
required within the ward
• Adequate storage space to contain therapeutic equipment will be required
within the ward.
• Sufficient space for physical activities and exercise
Planned clinical meetings
• Adequate space is required to provide for a variety of clinical meetings
which will take place on a daily basis
• Adequate space to comply with the new Mental Health (Scotland) Act
• Milan Suite
Other Meetings
• Appraisal/supervision meetings
• Educational meetings
• Meetings with extended care team
• Meetings with relatives
• Group Activities
Clinical risk management principles
• Based on this an initial risk management plan is developed.
• On admission each patient is assessed in accordance with the recognised
risk assessment tool.
• One element of this plan is to determine the person’s observation status.
• Risk management for this patient group is important. The environment
must be conducive to delivering the risk management plan
• IPCU will have systems and processes, from the pre-admission stage
through to aftercare, that ensure the multi-disciplinary assessment of the
health and social care needs of patients, and the risk of harm posed by
them to themselves and others. Assessments will then be used to inform
155
the treatment plan and enhanced Care Programme Approach.
Operational Procedures
Working day plans
• The ward will be open 365 days per year and 24 hours per day
Staffing arrangements and shift patterns
• Multi-disciplinary team ‘safety briefs’ & handovers will take place at set
times throughout the day as determined by the ward team
• The wards will be staffed 365 days per year and 24hours per day
• Staffing levels and shift patterns will be set out to achieve the optimum
level of therapeutic care in a safe and secure setting.
Admission procedures
• Admissions are accepted at anytime. Some are arranged on a planned
basis most are emergency
• As far as possible admissions should be during normal office working
hours and all requests for admission should be routed through the IPCU
Consultant, Staff Grade or on call junior doctor.
• Admissions directly from the community should be exceptionally rare, as
patients should be given the opportunity to be managed in an unlocked
environment first.
• Informal patients should not be admitted to IPCU, unless it is the last
available bed in Ayrshire. The patient must give informed consent to being
admitted to a locked ward. The patient should be moved to a more
appropriate setting at the earliest opportunity.
• Admissions from the courts or prison must be discussed and approved by
the IPCU Consultant or deputy.
Record-keeping storage
• All clinical case records require to be stored within a lockable cabinet
within a lockable room
• Items of secure stationery require to be stored within a lockable cabinet
Visiting arrangements
• Visitors are advised to contact the ward for advice regarding their visits
before they come to the ward. Visiting is programmed.
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• Children under school age are not allowed on the ward unless in
exceptional circumstances.
• Infants of mothers with Puerperal illnesses may be brought in to visit
provided permission is granted by the Charge nurse at least 24 hour
before hand.
Mealtimes/dining arrangements
• Cafeteria arrangements should be flexible and provide healthy eating
options and between meal snacks and access to beverages available
• Facilities must promote the ambiance of the meal experience.
Between meal snacks and access to beverages
• Cafeteria arrangements should be flexible and provide healthy eating
options and between meal snacks and access to beverages available
Laundry facilities and linen management
• A room is required to provide for washing, drying and ironing of personal
clothing.
• Patient’s relatives may take items home for laundering purposes but this
should be recorded by nursing staff in the appropriate manner.
Functional content
Number of Inpatient Beds/Treatment Spaces
• 8 single bedrooms with en-suite facilities
• 1 spacious clean utility/Treatment Room.
• 1 Activity area
• 1 fitness Suite
Investigative/Diagnostic/Treatment Capacity:
• This will be accessed via Crosshouse Hospital and other specialist
services.
Outpatient Service (Number of Sessions and
specialist functions):
• see clinical brief for outpatient department
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Specialist Technical Infrastructure Requirements
• Portable oxygen cylinders
• Secure Entry System – intercom at entrance to wards.
• Telephones for internal and external communications.
• Personal alarms
• PIN point system alarms
• Nurse Call System
• Immediate response
• Mobile phones for escort duties
• Emergency Response Pack
• ECG machine
• Emergency Medication Box for escort duties.
• Suction
• PCs for patient use
• Wii games console
Projected Future Activity
Key Relationships with Other Departments/NHS
Ayrshire and Arran /Social Services/Social
Work/Local Authority Services
Close to
Admission Ward
Forensic
Rehabilitation/Low
secure ward
•
•
•
•
•
•
•
•
•
•
Reason
Category*
Essential
Ease of transfer
Safety alerts
Extra staff
Patient privacy
Essential
Ease of transfer
Safety alerts
Extra staff
Patient privacy
Decanting
and
contingency
arrangements
Sharing of certain
secure spaces
158
Consultation &
Intervention Area and
outpatients department
•
•
Junior staff on-call
accommodation
•
•
•
Close to car parking area
•
•
Support Cluster 1
•
•
•
•
•
Desirable
Access
Co-located
staff
resulting in less
driving time
Desirable
Rapid response
24
hours/day
response
Delivery
of Essential
Ambulance
Services
Reliance Vehicles
Ease of access for Desirable
inpatients
Safety
Staff assistance
Accessible
for
visiting agencies
159
Future Service Delivery Risks
•
•
•
•
•
•
•
•
•
Changes in practice
Changes in diagnostic pattern for admission eg personality disorders,
challenging behaviour, ASD, brain injury, ARBD and changes in
diagnostic pattern for admission
New Crisis service – unclear impact on bed need
Ageing population – more elderly patients
Demographic changes
Integrated Care Pathways (ICP)
HEAT targets – readmission rates, suicide prevention etc
Positive risk taking
Other services
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Appendix N - Addictions Ward
Introduction and outline of services
Departmental Function
1.
Overview – Residential Addiction Unit
Addiction services provide a nurse led service to the population of Ayrshire
and Arran which is approximately 375,000 and covers three local authority
areas, of this population an estimated 50,000 experience problems with their
use of alcohol and around 8,500 have severe drinking problems and severe
drug problems.
The strategic leads for Ayrshire & Arran agreed a new model of service
delivery which governs alcohol and drug interventions across Ayrshire. This
Recovery Orientated System of Care (ROSC) was signed off in February
2011. The ROSC dictates that
‘The strategic vision for Ayrshire & Arran is:• Recovery is possible and at the centre of all services we provide.
• People will own their own recovery and service staff will facilitate
their recovery journey.
• People in recovery will support others along the path to recovery.’
This Residential Addiction Unit will combine the functions of alcohol
detoxification (detox), drug detox, addiction assessment and a day
programme within the North Ayrshire Community Hospital. This will
comprise of a recovery orientated, 10 bedded unit used flexibly to enable the
service to respond to rapidly changing population demands. All admissions
to the unit will be planned. Duration of admission will be range between 4
days to 4 weeks maximum depending on purpose of admission.
Scottish Government defines recovery as “a process through which an
individual is enabled to move on from their problem drug use, towards
a drug-free life as an active and contributing member of society [and] is
most effective when service users' needs and aspirations are placed at
the centre of their care and treatment".
There is an increasing national evidence base for the use of residential beds
as part of a recovery programmes and this direction is visibly supported by
the Alcohol and Drug Strategies of the three Alcohol & Drug Partnerships
(ADP) in Ayrshire and Arran.
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This unit will allow the inpatient addiction assessment and interventions to
focus on individuals with a greater complexity of need than is currently
possible within existing arrangements. Residential programmes should not
be stand alone intervention and in order for patients to progress throughout
their recovery journey it is imperative that they are given a range of
treatment options and choices as part of their overall integrated package of
care to support them on their road to recovery.
2.
The remit of the new Addiction Unit can be summed up as delivering the
following functions:
• Pre-planned detox from alcohol and or other drugs;
• Elective specialist in-depth assessment;
• Structured day programmes for both in-patient and out-patients in
order to prevent admission (step-up approach) or facilitate earlier
discharge (step-down approach).
Teams and Links
The 10 bedded Addictions Unit will be managed by nursing staff. The unit
will operate 24 hours/day 365 days per year.
Staff will primarily work 12 hour shifts (day and night) on a rotational basis.
The Addiction Staffing complement will be:
• 1 x band 7 Charge Nurse
• 1 x band 6 depute Charge Nurse
• 8 x band 5 staff nurses
• 5 x band 2 nursing assistants
Total number of staff = 15 wte
Staff in this unit will work within a recovery orientated, person centered,
multi-disciplinary and multi-agency framework in partnership with primarily
Community Addiction Teams (CAT’s) and Primary Care Addiction Teams
(PCAT’s) in North, South & East Ayrshire (6 teams in total).
All assessments, including risk assessment for in-patient residential
programmes will be undertaken by CAT and or PCAT staff and will be
updated on admission to this unit. All referrers will be in-reaching and
remain involved in the patient’s care at assessment, admission, up to and
including discharge and aftercare arrangements. CAT and or PCAT along
with in-patient staff and medical staff will consider appropriate options for
clinical patient management including step-up arrangements to prevent
admission to hospital or step-down arrangements to facilitate early
discharge.
These programmes will vary in intensity and duration depending on
assessment of need. The needs of the patients will direct the format of the
programme e.g. one day per week or seven days per week, ADP
commissioned services, and local recovery champions, will be integral
partners in complementing this step-up and step-down approach.
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Increased integration on a rotational basis of addiction community and inpatient staff will allow learning opportunities and promote an integrated
Recovery Oriented System of Care (ROSC) as agreed by Alcohol and Drug
Strategic Leads for Ayrshire & Arran in February 2011. This will ensure
consistency of approach within the staff groups across community and inpatient services. The provision of this aspect of the ROSC to include a fluid
and flexible model, of which group work is a core function, will enable the
development of recovery communities and essential linkages to support the
sustainability of goals for individuals. This provision within a discrete unit will
allow greater integration between the various interventions and more
efficient working practices.
The group programmes will be delivered in an environment conducive to
patient learning and be complemented by ADP commissioned recovery
services and recovery champions identified in each locality to offer support
and learning.
A wide range of statutory, non-statutory partners and commissioned
agencies may be engaged with patients throughout this process including
social work, Dietetics, Pharmacy, Physiotherapy, Occupational Therapy,
Dentistry, Podiatry, Tissue Viability, Continence Advisor, Hospital Chaplain,
Advocacy, Mutual Aid, Careers Scotland, Volunteers, Ayrshire Council on
Alcohol, Turning Point Scotland, Addaction, Strathclyde Fire and Rescue,
Smoking Cessation, ex patients groups and identified recovery champions.
AHP input is envisaged to be required on a flexible, needs lead basis and
the ability to respond to this should be reflected within individual AHP clinical
briefs.
3.
At any given time there could be up to 5 staff on duty within the unit and up
to 14 patients (10 residential and 4 day attenders) at a time. These numbers
may be supplemented by up to 2 student nurses, 1 member of medical staff
and up to 4 Allied Health Professionals (AHP’s), voluntary, statutory or
commissioned agency staff members. The unit will therefore be required to
accommodate approximately 10 staff members (including students, medical
staff, AHP’s, voluntary and statutory staff) and 14 patients at peak times,
which is a total of 24 people.
Service Users
All assessments for in-patient residential programmes will be undertaken by
CAT and/or PCAT staff. All referrers will be in-reaching and remain involved
in the patient’s care at assessment, pre-admission, admission, up to and
including discharge and aftercare arrangements. Where agreed with the
individual this will include relevant parties being invited to Multi-Disciplinary
Meetings including MDT Reviews, Care Programme Approach meetings,
Pre-Discharge Meetings, case conferences etc. This will streamline the
admission and discharge process and lead to reduction of time spent in
residential care and a reduction in the time from referral to discharge as
outlined below. This process will also comply with the Scottish Government
Drug and Alcohol waiting times as follows ‘by March 2013, 90 per cent of
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clients will wait no longer than 3 weeks from referral received to appropriate
drug or alcohol treatment that supports their recovery.’
Open referral to NHS CAT/PCAT Service – assess
suitability for community or in-patient intervention
<2
weeks
Assessed as suitable for
increased support or inpatient
intervention
Planned admission to Addictions Unit
for detox and/or assessment
Step up to intensive day
attendance group/1 to 1
programme, available 7 days/week
in order to try and prevent
admission
Flexible, client-centred intervention with full involvement
of community services and recovery champions
Immediate
access
Immediate
access
Step down to intensive day
attendance group/1 to 1
programme, available 7
days/week
<3
weeks
4 days –
4 weeks
Community support
Exit from residential service
Overall referral to discharge from residential services
Between 6 - 9 weeks
Patients may continue to be supported through step down or
community support arrangements.
Although this will be an adult admission area, both the accommodation and
delivery of care needs to be flexible enough meet the needs of mixed sex groups
with a range of ages and will include those who may have a physical disability and
or mild learning difficulties. This area will also be required to meet the needs of
out-patients attending for group work programmes
Patients will be admitted primarily as a result of complex addiction issues
undertaking more specialist in-depth assessment for individuals with severe and
complex alcohol and or drug and mental health related issues. A period of
assessment (up to 4 weeks duration) will cover in detail the nature and extent of
alcohol and drug use, physical and psychological health, personal and social
skills, social and economic circumstances, impact of previous treatment episodes
164
and the assets and attributes of the individual.
Patients may also have physical symptoms, which may be due to: a co-morbidity
of disease, because of dependence on drugs and/or alcohol or as a result of the
lifestyle choices made by some people with mental illnesses leading to a lack of
social skills and self neglect with a subsequent and often significant deterioration
in their state of physical well-being.
During the individual’s stay they will be encouraged to attend all therapeutic group
programmes and maintain and foster relationships with recovery communities and
family, relatives and friends who will also be encouraged to participate in and
support the person’s plan of care and participate in the person’s recovery
process.
4.
Therapies and Treatment
The aim of the Addiction Services inpatient facility is to deliver the right care, at
the right time, to the right patient.
Within this unit there will be dedicated space where group work sessions will be
available to the patient group and also areas for out-patients attending group day
programmes. These sessions may be delivered by a variety of staff such as
Addiction Staff, statutory, non-statutory partners and commissioned agencies that
individuals will incorporate into their individual recovery programmes in addition to
one-to-one time spent with their key worker or group sessions. Dedicated and
‘bookable’ space will be required within the unit to allow the facilitation of activity
programmes and the spaces will require to be flexible with the option to open up
dividing walls/partitions to allow for larger groups should that be required or for
social activity.
Meaningful activity will be vital within the Unit and this will require to be supported
by a comprehensive ongoing assessment. Activity will largely be scheduled and
will be co-ordinated and provided on a multi-disciplinary basis that will directly
involve the individual service users.
Group activity will be designed to address addiction related issues and will also
address the wider impact of addiction in relation to health and social care needs,
which typically include physical, psychological, recreational, life-skills, cultural,
spiritual and social elements.
Patients will be assisted by staff to take the lead in their own recovery plan and
will identify an individualised activity plan that will form the basis of their recovery
journey and will reflect their own personal needs, aspirations and attributes.
A key aim of this unit will be to provide an extension of community services to
165
enable patients to access step-up or step-down levels of support and intervention
as required and provide a platform for social inclusion by re-integrating the patient
into their local community at the earliest possible stage of their journey. Working
towards recovery and discharge will be the underpinning objective at all times.
Some individual therapies including patient consultations, psychological therapies
and advanced psychiatric assessments, will require private, confidential space
(significant sound insulation whilst not compromising safety), allowing individuals
the opportunity to express their emotions and personal issues.
Wherever possible patients will be encouraged to self cater in some way, whether
it is making a cup of tea and a snack through to fully self-catering all meals. Outpatients (day attenders) will not require mid-day or evening meals as the sessions
will be split between morning and afternoon sessions which will negate the
requirement for meals for this patient group.
5
Model of Care
Descriptive Overview
Entry
Recovery
champions
• Strategic
• Therapeutic
• community
Regular
Referral
IF APPROPRIATE
OR REQUESTED
Range of community
based peer support.
E.g. AA, NA, CA, Smart
Recovery and other
peer support
Self Referral
Pool of
communities in
recovery
Initial assessment
Rapid access, responsive, people- friendly
Full assessment
With specialist agency
Regular assessment of progress and case
management
TIER 1
TIER 2
TIER 3
Inpatient/
Residential
Specialist Alcohol
and drug support
services
Local services including
harm reduction team,
local counselling
services
Emphasis on
treatment
Emphasis on
treatment
Combined emphasis
on treatment and
TIER 4
recovery
Interventions available
within broader
community settings, such
as education, training,
welfare rights, housing,
meaningful activities and
employability services
Emphasis on recovery
focused support
SERVICES
Recovery advocates and peer support
Regular assessment of progress and case management
SERVICES
Raising aspirations and hope
COMMUNITY
166
Model above adapted from design by Lanarkshire ADP and used with kind
permission.
Approved at the Alcohol and Drug Strategic Leads meeting 18 February 2011
The Addiction Services inpatient facility will be a Tier 4 treatment focussed unit
as outlined above in Ayrshire & Arran’s ROSC.
Among those who seek and require help in dealing with their alcohol and or drug
problem there will always be those who need the availability of an inpatient stay.
This is recognised in all relevant national strategies and guidelines including
“Inpatient detox followed by residential rehabilitation is the most effective way for
drug users to become drug free, if they are motivated to be drug free and this is
the agreed objective” (National Treatment Agency - NTA 2005).
The staff working is this unit will have specialist addiction expertise and skill and
will focus on the major presenting issue of alcohol and drug problems. Central
to the workings of the ‘Addictions’ facility will be the delivery of clearly defined,
evidence based psychosocial interventions, delivered as part of an individuals
recovery support plan. Each individual will be assisted to make changes in their
alcohol and or drug using behaviour. Structured psychosocial interventions will
be identified within a recovery support plan and these interventions can be
delivered in an individual or group setting.
Examples of evidence based psychosocial interventions include:
• Cognitive behaviour therapy (CBT)
• Coping and social skills training
• Relapse prevention therapy
This unit will be abstinence based and have a clear and defined role which can
be summed up as delivering the following functions;
•
Pre-planned detox from alcohol and / or other drugs;
♦ Alcohol Detox - expected duration of admission 4 -7 days.
♦ Drug Detox – expected duration of admission 10 – 14 days.
♦ Elective specialist in-depth assessment;
Expected duration of admission, 4 weeks maximum.
♦ Structured day programmes for day attenders in order to prevent
167
admission (step-up approach) or facilitate earlier discharge (stepdown approach).
Day programme duration can be tailored to meet the individual
need of the patients
The functions above this will be considered an extension of Addiction Services
community service provision.
The community teams (CAT’s & PCAT’s) will assess patients whilst in the
community and book the beds and facilitate admissions to this unit. Community
staff will promote and ensure continuity of patient contact (via joint key worker
sessions) whilst their patient is in the Addiction unit and will facilitate discharge
planning and ensure follow up support is in place for all patients.
This patient group may have more complex and challenging mental illnesses
and behaviours associated with chaotic drug and or alcohol misuse than those
within the community environment. The facility environment will be conducive to
providing a therapeutic atmosphere to enable recovery focused, patient centred
care, encouraging behavioural change and relapse prevention through a range
of psychological/psychosocial interventions and therapies.
Alcohol Detox
Detox refers to the planned withdrawal of a substance. Alcohol withdrawal
carries risks and requires careful clinical management. Detox should be seen
as part of the recovery pathway.
Appropriate treatment of alcohol withdrawal can relieve the patient’s discomfort,
prevent the development of more serious symptoms and forestall cumulative
effects that might worsen future withdrawals. Hospital admission provides the
safest setting for the treatment of alcohol withdrawals, although many patients
with medication to moderate symptoms can be treated successfully via
community and home detox (Myrick and Anton, Alcohol Health and Research
World, Volume 22, No 1, 1998).
Signs and symptoms of alcohol withdrawal typically appear between 6 and 48
hours after heavy alcohol consumption decreases. Initial symptoms intensify
and then diminish over 24 to 48 hours. Delirium tremens (DT’s), the most
intense and serious syndrome associated with alcohol withdrawal usually
appears 2 to 4 days after the patients last use of alcohol.
Most individuals can detox safely and effectively in the community with intensive
support and appropriate medication. In Ayrshire, this home/community detox is
delivered by CAT/PCAT’s in partnership with individual GPs.
However, some individuals require acute medical admission. This is usually
indicated where there are co-existing medical conditions such as Delirium
Tremens, pancreatitis, pneumonia or other infections. Other indicators of an
168
acute medical admission include severe undernourishment, severe on-going
vomiting or diarrhoea or other acute physical illness.
For other individuals, where home/community detox is not safe or possible, preplanned admission to the ‘Addictions’ facility would be available. Relative
indicators for in-patient admission for alcohol detox include:
•
•
•
•
•
•
History of severe withdrawal symptoms including alcohol withdrawal seizures;
Multiple unsuccessful home/community detox interventions;
Concomitant psychiatric illness
Recent high levels of alcohol consumption
Lack of reliable community/home support network
Pregnant women – supported by Child Protection High Risk Pregnancy
Protocol
Individuals requiring in-patient alcohol detox would be admitted for the minimal
time possible. Discharge planning will be arranged as soon as withdrawal
symptoms subside with the ongoing support from their local PCAT who will
continue to monitor or administer medication related to alcohol withdrawal for
the remainder of their detox regimen. This practice will maximise bed
occupancy and continue to allow the service to respond to ever changing
demands.
Other Drug Detox
In dependent drug users, detox is usually thought of as being a clearly defined
process supporting safe and effective discontinuation of illicit substances while
minimizing withdrawals. Increasingly individuals are using alcohol and ‘cocktails’
of other drugs. In-patient detox would normally only be considered for
individuals who need a high level of nursing and medical support. Pre-planned
admission to the new ‘Addictions’ facility for in-patient detox may be indicated for
the following:
•
•
•
•
have not benefited from previous formal community-based detox
need medical and nursing care because of significant co-morbid physical
or mental health problems requiring complex poly drug detox, for example
concurrent detox from alcohol and or other substances
are experiencing significant social problems that will limit the benefit of
community-based detox
Pregnant women – supported by Child Protection High Risk Pregnancy
Protocol
However, some individuals require acute medical admission. This is usually
indicated where there is a co-existing presentation of acute and complex
physical conditions which may require a higher level of clinical management and
treatment. This may result in a transfer of care to the addiction unit when
deemed medically fit.
Staff will routinely offer a community based programme to all patients
169
considering drug detox. Individuals requiring in-patient drug detox would be
admitted for the minimal time possible. Discharge planning will be arranged as
soon as the optimum level of stability is achieved with the ongoing support from
their local CAT/PCAT who will continue to monitor medication related to drug
detox management for the remainder of their regimen. This practice will
maximise bed occupancy and continue to allow the service to respond to ever
changing demands.
Patients who do not successfully detoxify will be offered seamless access back
into maintenance and/or other treatment programmes identified to meet their
needs.
Elective specialist in-depth assessment
The ‘Addictions’ facility will also offer the availability of undertaking more
specialist in-depth assessment for individuals with severe and complex alcohol
and drug and mental health related issues. A period of assessment (up to 4
weeks duration) will cover in detail the nature and extent of alcohol and drug
use, physical and psychological health, personal and social skills, social and
economic circumstances, impact of previous treatment episodes and the assets
and attributes of the individual.
Effective assessment is an ongoing process and seeks to identify the range and
level of needs of the individual, not only the problems directly caused by
substance misuse, but also the health, social and economic impact. A key
feature of this assessment process is the exploration of the individual’s attitudes
and aspirations.
Structured day Programmes
The ‘Addictions’ facility will also offer the availability of some individuals
attending a structured day programme. This intervention can also be
incorporated into a step-up approach which is for individuals who may require a
more intensive support package to prevent admission to the residential unit or a
step-down approach following period of in-patient detox or specialist
assessment which may facilitate earlier discharge.
The structured day programme will offer a range of interventions with availability
of 8 x ½ day sessions each day (4 x full day sessions each day), 7 days per
week (56 sessions per week). Regular key worker sessions are a key element
of this structured day programme along with the ongoing development of
individualised recovery support plans, which address alcohol and drug misuse,
physical, mental health needs and associated behaviours and social functioning.
The overall programme will include group work, psychosocial interventions,
educational and life skills activities.
170
6
Role and Function
The Addictions inpatient facility provides assessment and an agreed plan of
care via a flexible nurse led, person centred approach which is recovery
focussed. The facility will offer evidence based interventions to service users
within a group and/or individual setting to enhance skill base allowing healthy
behavioural change to patients (as described in the descriptive overview).
The addiction inpatient facility will provide training, support, and consultancy to
other organisations and workers. The service acts as a source of expertise,
support and intervention to other professionals, patients and the community to
provide a comprehensive range of prevention and treatment services across
Ayrshire and Arran for alcohol and/or drugs.
The addiction inpatient facility will provide an inpatient, admission, assessment
learning environment for the University of West of Scotland nursing students,
each being supervised and supported by an experienced mentor. Further to
this, we also provide learning opportunities to post graduate students, including
nursing, medical, psychology and social work from a range of universities
throughout Scotland.
7.
Bed complement
The addiction inpatient bed numbers are:
•
10 inpatient beds
171
•
•
•
8.
Bed complement will also be DDA compliant
All beds should be single room accommodation with en-suite facilities
Bed provision will be in accordance with the mixed sex guidelines.
Planned patient length of stay
Patients will be admitted to this facility on a planned basis, with the approximate
average length of stay being 4-7 days for alcohol detox or 10-14 days for other
drug detox purposes.
Patients being admitted for residential specialist in-depth assessment will not
exceed 4 weeks.
The day programme offers availability for 8 individuals attending for a ½ day
session every day of for 4 individuals attending for a full day each. Therefore
different people could attend at different times and for different duration.
9.
General principles of operation
•
•
•
10.
All clinical, therapeutic and social care will be provided at the least
restrictive level appropriate to the needs of the patient group
Clinical interventions will be evidence based and reflect current best
practice
The addictions inpatient service will aim to provide a conducive
therapeutic environment in which a patient’s plan of recovery can be
assessed and treated to improve their psychological and physical
wellbeing and reduce the risk of relapse/self harm.
Design Synopsis
In addition to the core design synopsis/critical features, unique features to this
environment will be;
•
•
•
•
•
•
•
•
•
•
In keeping with anti-ligature and DDA and mixed sex accommodation
standards;
Single rooms with en-suite facilities;
Doors, locks and windows should be of a design which enables access by
staff in an emergency situation;
Through doors should have an appropriate viewing panel;
Maximum use of natural and artificial light;
Maximum use of natural and artificial ventilation;
Discreet storage services;
Dining facilities that enhance the meal experience;
Clinical areas that are non threatening and welcoming;
Social/Activity/Therapy area and sitting rooms should be therapeutic while
172
•
•
•
•
•
•
•
11.
Corridors: Required features
•
•
•
12.
The design of the facility must comply with current legislation
The building should be sensitive to the needs of physical and sensory
disabled patients, staff and visitors.
Privacy and dignity requirements
•
15.
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
•
•
14.
Corridors should have no blind spots and allow maximum observation
Long unbroken corridors should be avoided, with the maximum use of
natural light and ventilation.
Well signposted
Mixed gender requirements
•
13.
lending themselves to recovery;
The provision of hot/cold drinks should be available in the pantry which
should be en-suite to social/activity/therapy area;
Bedroom areas should enhance the therapeutic experience and also
provide privacy;
All areas within the facility should be easily observable with no blind spots
Ligature points should be eliminated;
Outside smoking area should be well ventilated thereby preventing smoke
pollution of adjacent areas, if legislation allows;
Doorways should be wide enough to allow ease of access for disabled
access;
Calming features built into the fabric of the building.
The design of the unit must comply with current legislation
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
16
Required adjacencies
External
•
•
Outdoor garden area should be safe and stimulating with a smoking
shelter(legislation permitting);
Sheltered outdoor activities area partially covered, allowing fresh air;
173
•
•
•
•
The garden area should be landscaped and easily maintained;
The addiction inpatient facility should be adjacent to the adult admission
facility and connected by a common corridor;
The facility should have easy access to Support Cluster 2 without having
to go outside;
The facility should be close to the recreational facility.
Internal
•
•
•
•
•
•
•
•
•
The open plan dining room and pantry should not be next to the bathroom
facilities;
Staff base for 3 staff should be at the area of highest observation;
Duty room should have a certain amount of observation;
Store room, linen room, clean and dirty utility room, cleaners’
housekeeping room, WC should be clustered together. This should be
away from the clinical area and bedrooms;
Patient’s laundry should be distant to the bedrooms and
social/activity/therapy area;
Duty room and staff base for 2 places (hot desk with IT access) should be
clustered together;
The bedrooms should be distant from the social/activity and therapy area;
The sitting room should be sited in accordance with the mixed sex
guidance;
The social/activity/therapy area, sitting room and pantry should be sited in
such a way that allows ease of access and use but distant from the
bedrooms.
•
17.
Storage facilities
The following storage facilities are required for:
•
•
•
•
•
•
•
18.
Anticipated developments
•
•
•
19.
Secure lockers for 15 staff;
Flat linen and towels;
Spare duvets and pillows;
Activities store including seasonal decorations;
Medical record storage space;
Stationery cupboard;
Central Storage room for miscellaneous items (large).
The building should be flexible in design to meet the challenges of an
ever changing and improving Health Service;
The building should be able to meet the needs of future Information
Technology developments;
Any future developments within all relevant guidelines and standards.
Client Group Characteristics
174
Age and Gender
•
•
20.
Admission Rates
•
21.
16 to 65 years old although sometimes exceptional circumstances will
lead to some flexibility.
Male and Female
Facility will be open 365 days per year and admissions can be facilitated
at any time.
Admission Criteria
• Pre-planned detox from alcohol and / or other drugs;
• Elective specialist in-depth assessment;
• Structured day programmes for both in-patient and out-patients in order to
prevent admission (step-up approach) or facilitate earlier discharge (stepdown approach).
Alcohol criteria
• History of severe withdrawal symptoms including alcohol withdrawal seizures;
• Multiple unsuccessful home/community detox interventions;
• Comorbid psychiatric illness
• Recent high levels of alcohol consumption
• Lack of reliable community/home support network
• Pregnant women – supported by High Risk Pregnancy Protocol
Drug criteria
• have not benefited from previous formal community-based detox
• need medical and nursing care because of significant co-morbid physical or
mental health problems requiring complex poly drug detox, for example
concurrent detox from alcohol and or other substances
• are experiencing significant social problems that will limit the benefit of
community-based detox.
• Pregnant women – supported by High Risk Pregnancy Protocol
The presentation/admission requirements to access this service are as follows:
•
•
Need for inpatient detox (criteria & procedures, as per protocols and
guidelines for NHS Ayrshire and Arran inpatient detox, are well
established)
A requirement to deal with complex mix of significant alcohol and/or drugs
and severe mental illness or mental health issues
175
Guiding principles which dictate admission is a complex issue however, the
available national guidance stipulates that the requirements are;
•
•
•
•
•
•
•
Individuals who are unable to achieve and maintain abstinence in a
community setting;
Those who express a desire to maintain abstinence and express a
preference for admission addiction programmes or agree to enter this
type of programme;
Those who are likely to have substantial problems maintaining abstinence
due to the severity of their substance dependence;
Those requiring a programme of addiction support that is most suitably
delivered in a residential environment;
Those who are living in an environment characterised by social
deprivation, including housing problems or instability, which represents a
threat to relapse;
Those who lack social support;
Those whose social environment contains people (e.g. partners, friends)
who are substance misusers and who are likely to hinder resolve or ability
to maintain abstinence.
The proposed DDA compliant, single room accommodation will allow flexibility in
admission presentation and allow the service to react and respond to local
rapidly changing demand.
22.
Anticipated illness-related behaviours
Patients who are admitted to this facility may display the following:
•
•
•
•
•
•
23.
Intoxification
Disinhibited behaviours
Unpredictable and impulsive behaviours
Aimless or ritualistic behaviours
Lack of personal risk awareness
Patients in the facility are more likely to have complex needs as described
in the appropriate sections of the ICD 10, Classification of Mental Health
and Behaviour Disorders
Anticipated clinical risks
Patients who are admitted to this facility will be at an increased risk from the
following:
•
•
•
•
•
•
•
Absconding;
Deliberate self harm
Intoxication
Illicit alcohol/drug use
Inappropriate relationships/co-dependency with patients and staff
Harm to others
Self neglect
176
•
•
•
24.
Challenging behaviour
Suicidal intention
Disinhibited behaviour
Patient dependency characteristics
Principal aims of clinical care
Usual admissions to these areas will represent patients who undergo:
•
•
•
•
•
•
•
•
•
Addiction assessment including assessment of risk, development of
recovery plans and appropriate treatment interventions
Timeous discharge planning supported by CAT’s and PCAT’s;
Initial support, assessment identification of ARBD;
Promote positive behaviour change related to the individuals
psychological well being
Integrated relapse prevention work based on Prochaska and Di
Clementes Transtheroretical model of change and Marlatt’s relapse
prevention model
Physical health screening and non-complex interventions
Care and Treatment is underpinned by the Milan Principals and 10
Essential Shared Capabilities.
The Therapeutic model within this unit is based on the tidal model of
recovery
Strategic drivers – Rights Relationship and Recovery, Road to Recovery,
Closing the Gaps – Make a Difference: Commitment 13; Do the Right
Thing – How to Judge a Good Ward
•
25.
Therapies
•
•
•
•
•
26.
A range of addiction specific interventions will also be delivered, for
instance, relapse prevention;
Complementary therapies will be delivered as appropriate in line with new
guidance emerging from the current review within the Mental Health
Partnership and Professional Groups, for instance, Nursing & Midwifery
Council (NMC);
Individual and group therapies will be provided within the facility in
keeping with the care plan and models of care;
Therapies should be in keeping with recovery/tidal model and be
evidenced based, for instance, CBT, motivational interviewing, family
therapy, psychosocial interventions, solution focussed therapy etc; and
Therapies will enhance the care experience and will be focussed upon
specific interventions and outcomes.
Therapeutic facilities required
•
Space to provide therapeutic interventions as required within the facility
177
•
27.
Planned clinical meetings
•
•
28.
Appraisal/supervision meetings
Educational meetings
Meetings with extended care team
Meetings with relatives
Clinical risk management principles
•
•
•
•
•
30.
Space is required to provide for a variety of clinical meetings which will
take place on a daily basis
Space to comply with the new Mental Health (Scotland) Act
Other Meetings
•
•
•
•
29.
Storage space to contain therapeutic equipment will be required within the
facility as previously described.
Based on this an initial risk management plan is developed;
On admission each patient is assessed in accordance with the recognised
risk assessment tool;
One element of this plan is to determine the patient’s observation status;
Risk management for this patient group is important. The environment
must be conducive to delivering the risk management plan;
The Addictions facility will have systems and processes, from the preadmission stage through to aftercare, that ensure the multi-disciplinary
assessment of the health and social care needs of patients, and the risk
of harm posed by them to themselves and others. Assessments will then
be used to inform the treatment plan and enhanced Care Programme
Approach.
Operational Procedures
Working day plans
•
•
The facility will be open 365 days per year and 24 hours per day;
The addiction inpatient facility will provide crisis intervention/support via
telephone contact 24hours a day, 7 days a week.
Staffing arrangements and shift patterns
•
•
Nursing handovers will take place in the duty room at set times
throughout the day as determined by the facilities team;
The facility will be staffed 365 days per year and 24 hours per day;
178
•
Staffing levels and shift patterns will be set out to achieve the optimum
level of therapeutic care in a safe and secure setting.
Admission procedures
•
•
•
•
•
Admissions are accepted on a planned basis and will be facilitated to
accommodate the individual presentations
As far as possible admissions should be during normal office working
hours and all requests for admission should be routed through the
facilities staff;
Admissions will be directly from CAT and /or PCAT staff;
It is envisaged that the majority of admissions will be on an informal basis;
At times patients could be detained under the Mental Health Care &
Treatment (Act) (Scotland) 2003.
Record-keeping storage
•
•
•
All clinical case records require to be stored within a lockable cabinet
within a lockable room
Secure IT systems for patient records
Items of secure stationery require to be stored within a lockable cabinet
Visiting arrangements
•
The intention is to have both timed and flexible arrangements for visitors,
including children in line with the protected mealtime policy.
Mealtimes/dining arrangements
•
•
•
•
Dining will be facility based and there will be three mealtimes per day;
Facilities must promote the ambiance of the meal experience, and not be
cramped;
Facilities must be available to permit the consumption of hot and cold
drinks out with recognised mealtimes;
There will be a pantry area for patients to access these beverages.
Between meal snacks and access to beverages
•
•
Facilities must be available to permit the consumption of hot and cold
drinks out with recognised mealtimes
There will be a pantry area for patients to access these beverages
Laundry facilities and linen management
179
•
A room is required to provide for washing, drying and ironing of personal
clothing.
Adult Recreational Facility
•
•
•
•
31.
Access to physical activities in the facility, for instance, treadmill, multigym, wii fit, table tennis, pool table;
Sitting room (quiet room);
Promotion of wellbeing, library, access to reading materials, interactive,
board games as described with STAR Wards, further information on
STAR Wards can be access by www.starwards.org.uk;
Access to physical activities available at the leisure centre.
Functional content
Number of Inpatient Beds/Treatment Spaces
•
•
•
10 in-patient beds with en-suite
Treatment room, general and UVL both sides couch access for 1 patient
Investigative/Diagnostic/Treatment Capacity:
•
•
•
•
A & E attendance/arranged appointments/transfer of patients to medical
wards on occasions to treat physical conditions;
EEGs and ECGs and CT scans are provided at Ayr or Crosshouse
Hospital as appropriate;
Medical staff and nursing staff carry out routine blood tests on admission,
and any further blood tests as indicated; and
Ability for nursing staff to access computer blood results.
Outpatient Service (Number of Sessions and specialist
functions):
•
Please see the Schedule of Accommodation for the consultation and
interventional area for further details.
Specialist Technical Infrastructure Requirements
•
•
•
•
•
•
•
Addiction educational resources, for instance leaflets, educational
material, books;
Mobile Phones for on call arrangements/emergencies;
Pinpoint Alarm system;
Portable Oxygen;
Portable Suction;
SAMS (Shared Addictions Management System) Addictions IT system.
FACE (electronic patient record for Mental Health);
180
•
•
•
32.
Projected Future Activity
•
•
•
•
•
33.
Nurse call system;
Telephones for internal and external communication;
Security entry out of hours – intercom at entrance to ward
Demographic differentials for age (reducing) and gender (increasing
incidence of women with problems);
Increasing alcohol consumption is likely to increase problems by 20%;
Nature of problems will change e.g. greater number of Alcohol Related
Brain Damage at earlier age, increase physical health burden;
New screening and Brief Intervention work will identify additional referrals;
Previous drug prevalence studies (Scottish Government/Glasgow
University) indicated a prevalence of 1.7% of the adult population in
Ayrshire with a significant drug problem (awaiting release of updated
study Summer 2009).
Key Relationships with Other Departments/NHS Ayrshire
and Arran /Social Services/Social Work/Local Authority
Services
Close to
CAT and PCAT (North
Ayrshire) NHS and
Local Authority
Admission Wards
Outpatients department
•
•
•
•
•
•
•
Medical staff
(psychiatric)
•
•
•
Support Cluster 2
•
•
•
•
•
•
Reason
Continuity of care
Category*
Essential
Essential
Ease of transfer
Safety alerts
Extra staff
Patient privacy
Desirable
Access
Co-located
staff
resulting
in
less
driving time
Essential
Rapid response
24
hours/day
response
Ease of access for Desirable
inpatients
Safety
Staff assistance
Accessible for visiting
agencies
•
181
34.
Future Service Delivery Risks
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Activity levels unpredictable
Activity/case mix change
Affordability
Commissioning plan
Communication plan
Consideration for smoking cessation - support to staff and patients
Decanting of services
Decommissioning plan
Engagement with key stakeholders to create new model of care prior to
transfer – transitional risk – preservation of good practice already
established, change management
Expectations of patients and staff, and the public
Familiarisation with local facilities, town centre, parks, shops
Full risk management plan
Group dynamic within patients
Impact on new service to statutory and non-statutory addiction services,
localities, patient group
Increase staff for increased number of patient
Lead-in time for testing service/environment
Ligature points
Ongoing support from Emergency services and local police services,
current A & E hospitals, social work,
Patient security
Settling in period may increase risks initially
Snagging lists
Staff Resources
Stigma, sensationalism through media of patient group
Sustainability
Training and support for staff
Transport – access and bus service for staff and visitors, carers and
patients (timetables)
Workforce – managing change for staff
182
Appendix O – Forensic Rehabilitation Unit (Low
Secure)
Introduction and outline of services
Departmental Function
Context
The Forensic Rehabilitation Unit is a continuation of the development which
took place on Ailsa campus providing an in-patient service for up to ten
Mentally Disordered Offenders some of whom were receiving their care outwith NHS Ayrshire & Arran.
This was initially an interim arrangement as it was envisaged that a Low
Secure Unit and Rehabilitation Unit would be built as part of the development
on NACH. The current anticipated need would suggest that the Low Secure
provision would be more financially viable by a Service Level Agreement with
a Low Secure Unit as there would appear to be more of a requirement to
provide rehabilitation beds in the immediate future.
There is a possibility however that the requirement for low secure provision
may increase therefore the 8-bedded Forensic Rehabilitation Unit is being
designed with the future option of being converted in use to a Low Secure
Unit by being built to the same specifications and overall design as IPCU
which meets the specification of a Low secure Unit.
1
Throughout the clinical brief the unit will be referred to as Forensic
Rehabilitation Unit (FRU) but it is implicit that the unit may change function at
a later date to become a Low Secure unit.
Key principles
The key principles for the development of integrated forensic mental health
services should include:
Regard to quality of care and proper attention to the needs of the individual;
As far as possible in the community rather than in institutional settings;
Under conditions of no greater security than is justified by the degree of
danger they present to themselves or others;
In such a way as to maximise rehabilitation and their chances of sustaining
183
an independent life; and
As near as possible to their own homes or families as appropriate.
Consideration for service delivery should include;
2
Integration with Community Forensic Mental health services;
Clear care pathways from high to medium to low to community and vice
versa;
Integration with forensic managed care network; and
Working definitions for the different categories of secure care.
Teams and Links
3
Our FRU will be Consultant led and managed by nursing staff working within
a patient/person-centred, multi-disciplinary and multi-agency framework in
partnership with, physiotherapy, dietetics, occupational therapy, speech &
language therapy, advocacy, social work, psychology, medical staff, criminal
justice team members and a range of visiting support services. Strong
working links will be maintained with the Forensic Community Team.
At any given time there could be up to 6 nursing staff on duty (variable with
clinical demand), this may be supplemented by 2 Student Nurses. When the
number of Medical (Consultants, Junior Doctors and Trainees), Allied Health
Professionals and representatives of other agencies are added to this it is
possible that up to 16 staff may be present and will require to be
accommodated on the ward at peak times. (These numbers would increase
should the unit become a fully functioning Low Secure Unit).
Service Users
The accommodation and delivery of care must be flexible enough to meet the
needs of people of all ages including those who may have a physical
disability.
4
All clients will be subject to detention in hospital under the terms of the Mental
Health (Care & Treatment) (Scotland) Act 2003 or the Criminal Procedures
Act (1995).
The patients will usually have more complex and challenging illnesses and
behaviour, some of these may manifest themselves in increased levels of
184
violence and aggression, they may also have physical symptoms, which may
be due to a co-morbidity of disease or because of dependence on drugs
and/or alcohol.
Patients will receive assessment, treatment and rehabilitative care within the
ward.
Therapies and Treatment
A key role of the ward will be to lead in the resettlement process of patients
from secure facilities to a community setting.
The care team will assist the individual in taking an active role in their
recovery by providing a range of therapeutic activity/interventions.
Activity, supported by a comprehensive ongoing needs and risk assessment,
may be scheduled or unscheduled, and will be co-ordinated and provided
from a multi-disciplinary perspective which will encourage involvement of the
patient/carer as a key part of the team.
Activities will be designed to address a spectrum of health and social care
needs which typically include physical, psychological, offence related,
recreational, life-skill, cultural, spiritual and social elements.
5
Each person will be engaged with a care plan for each day of their stay,
which reflects their needs, wishes and aspirations and is cognisant of their
capabilities with due regard to any requirement for enhanced safety and
security.
The service is recovery focused, it provides intensive treatment and
interventions to patients who require an increased level of observation and
security.
The FRU aims to provide a therapeutic environment in which patient’s
illnesses can be assessed and treated and thereby improve their
psychological (and physical) well being and where their rehabilitation needs
can be addressed, enabling better integration into the community on
discharge.
Some individual therapies including patient consultations, psychological
therapies and advanced psychiatric assessments, will require private,
confidential space (significant sound insulation whilst not compromising
safety), allowing individuals the opportunity to express their emotions and
personal issues.
185
Space and Observation
Although an open ward access to and egress from the FRU will be strictly
controlled and will require a high level of “perimeter” security (windows, doors,
airlock entry etc). To ensure safety security and observation is optimised all
ward facilities should be on a single level. These security provisions will be
designed into the building when being constructed but systems such as the
airlock entry will not be utilised as such unless the unit does adopt the Low
Secure function.
The feeling of space plays a key role in reducing levels of anxiety and
aggression and promoting recovery and, as such, it is of the utmost
importance that all patients have access to private and communal space both
internally, in the form of small quiet areas and externally in the form of
significant, safe, secure therapeutic green space. Where patients are unable
to leave a ward area as a result of their illness/behaviours the provision of
space is increasingly important in promoting recovery.
6
Within the FRU emphasis has been placed on encouraging social /
community activity.
Division of clients by function (assessment, treatment and rehabilitation) and
gender (male, female) will be an operational issue and will require a flexible
arrangement of room functions, e.g. bedrooms need not be in separate wings
but all eight rooms should not be next door to each other perhaps in smaller
groups (4- 4) separated by sitting areas/multifunction rooms.
Some clients may have to spend extensive periods (18 months to 2 years in
FRU function and longer if Low Secure) within the unit and as such will not be
able to access external recreational, educational and community services. In
keeping with the Millan principle of Reciprocity it is imperative that a
significant provision of common / activity space is made within the unit to
offset the impact of these restrictions.
During the patients stay they may be regularly visited by family, relatives and
friends who can also be involved in supporting the plan of care and
participate in the person’s recovery. These visits will be on a planned basis.
Legislation & Governance
We are governed by legislation which directs us to provide practical solutions
for patient/public safety and security (Criminal Procedures Act 1995)and also
the principles under the Mental Health (Care and Treatment) (Scotland) Act
2003:
Non-discrimination - people with a mental disorder should, wherever
possible, retain the same rights and entitlements as those with other health
needs.
186
Equality - all powers under the Act should be exercised without any direct or
indirect discrimination on the grounds of physical disability, age, gender,
sexual orientation, language, religion or national, ethnic or social origin.
Respect for diversity - service users should receive care, treatment and
support in a manner that accords respect for their individual qualities, abilities
and diverse backgrounds and properly takes into account their age, gender,
sexual orientation, ethnic group and social, cultural and religious background.
Reciprocity - where society imposes an obligation on an individual to comply
with a programme of treatment and care, it should impose a parallel
obligation on the health and social care authorities to provide safe and
appropriate services, including ongoing care following discharge from
compulsion.
Informal care - wherever possible care, treatment and support should be
provided to people with mental disorder without recourse to compulsion.
Participation - service users should be fully involved, to the extent permitted
by their individual capacity, in all aspects of their assessment, care, treatment
and support. Account should be taken of both past and present wishes, so far
as they can be ascertained. Service users should be provided with all the
information and support necessary to enable them to participate fully. All such
information should be provided in a way which renders it most likely to be
understood.
Respect for carers - those who provide care to service users on an informal
basis should receive respect for their role and experience, receive
appropriate information and advice, and have their views and needs taken
into account.
Least restrictive alternative - service users should be provided with any
necessary care, treatment and support both in the least invasive manner and
in the least restrictive manner and environment compatible with the delivery
of safe, effective care, taking account where appropriate of the safety of
others.
Benefit - any intervention under the Act should be likely to produce for the
service user a benefit which cannot reasonably be achieved other than by the
intervention.
Child welfare - the welfare of a child with mental disorder should be
paramount in any interventions imposed on the child under the Act.
187
Schedule of Accommodation
The accommodation is scheduled in Mental Health Services and is described
in the section entitled Low Secure in the Schedule of Accommodation.
Model of Care
Descriptive Overview
The FRU will have a clear and defined role in providing support to Mentally
Disorder Offenders. The patients will usually have more complex and
challenging illnesses and behaviour; some of these may manifest themselves in
increased levels of violence and aggression. The ward environment will be
conducive to enabling greater observation, security and support to patients that
exist within the open wards and to similar level of that within IPCU.
The aim of the FRU is to deliver the right care, at the right time, to the right
patient. These aims should be delivered through a system of:
needs assessment;
risk assessment;
risk management; and
treatment planning and delivery.
Each of these processes will be conducted as part of a structure or system in
order to realise a number of benefits including:
All of the multi disciplinary team caring for the patient, the patient themselves
and their carers should be able to share information regarding the identified
needs, risks, objectives, interventions and treatments;
Each should understand decisions that are being made and have reasonable
expectations of what should be delivered and when; and
The multidisciplinary team should be able to use the assessment and planning
structure to avoid duplication in their work, identify any gaps and to prioritise the
interventions, treatment and support they provide.
The overall environment within the ward should be conducive to providing care
within a safe setting that promotes the recovery process.
188
As a minimum standard the environment will comply with the Department of
Health Document “Mental health policy implementation guide: National minimum
standards for general adult services in Psychiatric Intensive Care Units (PICU)
and Low Secure Environments” which can be downloaded using the following
link.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic
yAndGuidance/DH_4010439
Role and Function
The FRU operates as a specialist service located within adult mental health inpatient services but also works very closely with the Community Forensic Mental
Health Team.
The FRU’s function will be to essentially provide assessment and care for
people who:Suffer from mental disorder, the nature and degree of which is such that they
require assessment and / or treatment in a secure ward setting, in the interest of
their own health and safety, and/or for the protection of others;
Because of above they require to be detained in hospital under the terms of the
Mental Health (Care & Treatment) (Scotland) Act 2003 or the Criminal
Procedures Act (1995);
(If become a Low Secure Unit) Are suspected mentally disordered offenders
remanded by the courts under the Criminal Procedures Act 1995 and who
because of their propensity for aggressive behaviour, cannot be adequately
managed within the ordinary acute psychiatric ward setting, or are restricted due
to being remanded back to hospital, therefore requiring a secure forensic low
secure unit;
FRU will operate with a consultant-led multi-disciplinary team of medical, nursing
and other AHP (allied health professionals) staff;
It is expected that the expertise of AHP staff like psychology, occupational
therapy and physiotherapy will be integral components of the service;
Clinical responsibility for all patients, during their stay on the ward is primarily
189
that of the ward consultant;
FRU will work in close co-operation with the source of referral at all times; and
Care will be patient centred with their privacy and dignity being preserved at all
times.
The service must balance the need for safety and security with the provision of a
therapeutic environment.
Care will be patient centred;
Services must respect the individual;
Services must offer privacy and dignity;
Services must balance the need for safety and security with the provision of a
therapeutic environment;
The environment requires to lend itself to obtrusive and unobtrusive observation;
and
The environment must be pleasant, safe and the general ambience promotes
mental health well being.
Bed complement
6 rehabilitation en-suite bedrooms, one with an en-suite ‘special care’ area
2 larger sized en-suite bedrooms to cater for mobility impaired or bariatric
patients
Planned patient activity
Admissions will be accepted from a variety of sources such as:
Low/Medium Secure Units
IPCU/Admission wards
Rehabilitation wards
Usual admissions to this area will represent clients who cannot be safely
managed in an open acute ward environment by virtue of:
190
requiring high levels of prolonged observation and high nurse patient ratio;
presenting a significant risk of harm to others; and
requiring to be in hospital as part of their compulsion under the terms of the
Mental Health Act or Criminal Procedures Scotland Act require secure
accommodation.
General principles of operation
•
•
•
•
•
•
All clinical, therapeutic and social care will be provided at the least
restrictive level appropriate to the needs of the client group;
Clinical interventions will be evidence based and reflect current best
practice;
Invasive clinical interventions such as restraint and rapid
tranquilisation will be undertaken in a safe, non stimulating
environment that respects the individual’s privacy and dignity; and
The FRU will aim to provide a therapeutic environment in which
patient’s illnesses can be assessed and treated and thereby improve
their psychological and physical wellbeing; control their aggression
and reduce the risk of self harm.
The Unit will aim to support individuals to work towards a discharge
within 18 – 24 months from admission to the Unit
All individuals in the FRU should be supported towards being fully
self-catering as quickly as is possible
Design Synopsis
•
•
•
•
•
•
•
•
•
•
•
•
•
In addition to the core design synopsis/critical features, unique
features to this environment will be;
In keeping with IPCU care standards (matrix of security);
Where possible, it would be preferable to have a single sex
facilities/bedroom areas;
Doors, locks and windows should be of a design which is antibarricade and enables access by staff in an emergency situation;
Maximum use of natural and artificial light;
Maximum use of natural and artificial ventilation;
Discreet storage services and sufficient storage (within and outwith
bedrooms) for personal belongings;
Dining facilities that enhance the meal experience including an ADL
kitchen and dining room;
Clinical areas that are non threatening and welcoming;
Common sitting and activity areas should lend themselves to recovery;
The provision of hot*/cold drinks should be available in the common
sitting/activity areas (*With the provision to be secured and accessible
only when supervised by staff dependent on risk);
Bedroom areas should enhance the therapeutic experience and also
provide privacy;
There will need to be flexibility for 1 bedroom to be ‘switched’ without
191
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•
•
•
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•
compromising mixed sex guidelines;
All areas within the ward should be easily observable with no blind
spots;
Ligature points should be eliminated;
Designated smoking area should be outside;
Garden areas should provide colours of plants and sensory
stimulation, sheltered areas, suntraps and comfortable seating;
Doorways and corridors should be wide enough to allow ease of
access for a patient under physical restraint;
Air Lock entrance to ward.( Reception/Waiting area) This entrance
(two sets of double doors) are an important security measure and
must be retained although may not be utilised in the initial time whilst
functioning as an FRU;
Windows should only open if external area is secure (to prevent
unauthorised items being passed into unit); and
Calming features built into the fabric of the building.
The design synopsis should include the following aspects :
Forensic Rehabilitation Unit (Low Secure)
ENVIRONMENTAL SECURITY
DESIGN AND CONSTRUCTION
Secure outside area;
Secure external windows;
Double locked doors (will be unlocked when FRU);
Specifically designed to deter escape;
Window restrictors / reinforced windows;
Doors opening outward (interview room and bedroom), window restrictors /
reinforced windows; and
Pinpoint type alarm system.
EQUIPMENT
Hand held metal detector; and
Limited to specific locations.
PROCEDURAL SECURITY
COMMUNICATIONS
Patients phone calls - No restriction except in “exceptional circumstances”;
192
Patients letters - Can be monitored under mental health legislation; and
Patients electronic mail / access to the internet - Supervised access on site
unsupervised off site.
ITEMS – RESTRICTED (or prohibited)
Searching patients - On admission including possessions and as warranted
by individual risk assessment - random searches following length of stay;
Drug access/screening - Urinary drug screening on basis of clinical need and
on admission & random screening; and
Alcohol access/screening - Access to alcohol on leave approved by MDT.
Alcometer available.
ITEMS – Daily living equipment
Sharp Kitchen knives – counted after use (will require supervised use if Low
Secure)
Cutlery – (if Low Secure) Restricted metal cutlery - counted after use,
supervised meals;
ADL kitchen – (If Low Secure - MDT approval); and
Fire setting materials (e.g. cigarette lighters) – (If Low Secure) Controlled/
limited access, no fire setting material with patients.
ITEMS - Access to money, valuables and belongings
Access to belongings - At MDT discretion;
Access to money/valuables - Dependant on individual assessment of
capacity. Will be restricted; and
Patients should have small safes or lockable drawers in their bedrooms.
PROCEDURAL SECURITY
PEOPLE- Child Visitors - approved by MDT
Child visiting policy - approved by MDT; and
Visiting arrangements procedure - Specified visiting areas (other restrictions
dependant on risk present at time).
PEOPLE- Internal Movement between clinical areas in a psychiatric facility
Patients - may be escorted;
Visitors / official visitors – Escorted; and
Provision of recreations/therapies – Range.
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PEOPLE- Patient absence from the hospital
Routine pass (e.g. “testing out”) - Unit policies including individual risk
assessment; and
Exceptional LOA (e.g. court, hospital) - Unit policies including individual risk
assessment.
Miscellaneous
Contingency planning - Multi-agency planning for evacuation, escape and
absconsion;
Window / door security - Standard hospital specifications; and
Furniture design - standard hospital furniture.
EQUIPMENT
X-ray / metal detector / ion detector - None routinely used;
Personal alarm systems – PinPoint alarm system;
Physical restraints - None used; and
Availability of additional special care area for behaviourally disturbed
patients.
In addition to the core design synopsis/critical features, unique features to
this environment will be:
•
•
•
•
•
•
•
•
•
•
•
•
Doors, locks and windows should be of a design which is antibarricade and enables access by staff in an emergency;
Maximum use of natural and artificial light;
Maximum use of natural and artificial ventilation;
Discreet hotel and storage services;
Dining facilities that enhance the meal experience, ADL kitchen and
dining room;
Clinical areas that are non threatening and welcoming;
Common social/activity/therapy areas should be domestic while
lending itself to recovery;
The provision of hot/cold drinks, controllable by staff, should be
available in the pantry;
Bedroom areas should enhance the therapeutic experience and also
provide privacy;
There will need to be flexibility in 1 of beds without compromising
mixed sex guidelines;
All areas within the ward should be easily observable with no blind
spots;
There should be one single point of entry to the ward;
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•
•
•
•
Ligature points should be eliminated;
Designated smoking area should be outside;
Doorways should comply with management of aggression guidelines;
Airlock entrance to ward is essential; and
1 Special care area comprising of living area en-suite to1 bedroom.
The special care area is a discrete, self contained living space, where those
very disturbed patients, who are also very disturbing and disruptive to other
patients, can be safely, humanely and effectively nursed separated from the
rest of the ward.
The special care area should be:
•
•
•
•
•
•
Discrete, lockable and to one end of the ward to minimise noise
disturbance;
Self contained with a living area en-suite to 1 bedroom;
Safe with minimum furniture made from pre-cast foam;
Capable of having a minimum of 2 staff in attendance at all times;
Designed to allow for the activities of daily living to be maintained in a
humane environment; and
Non stimulating.
Corridors: Required features
Corridor design is an important feature within the ward and should not just be
seen as a means of getting from A to B
Should be kept to a minimum
Corridors should provide seated areas for quiet contemplation
Corridors should have no blind spots and allow maximum observation
Mixed gender requirements
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
The design of the facility must comply with current legislation
The building should be sensitive to the needs of physical and sensory
disabled patients, staff and visitors.
Privacy and dignity requirements
The design of the unit must comply with current legislation
195
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
•
•
•
The FRU should be adjacent to the IPCU and connected by a
common corridor;
The FRU should be adjacent to the AMH Rehabilitation Unit and as
such have easy access to Support Cluster 2 without having to go
outside; and
The unit should have access to enclosed, secure, safe and
stimulating garden areas.
Internal
•
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•
The open plan dining area and pantry should be close to the entrance
of the ward and distant to the bedrooms;
The base for 3 staff should be in the centre of the ward to maximise
observation;
Store rooms, linen room, clean and dirty utility rooms, cleaner’s
(housekeeping) room, staff WC should be clustered together and
prevent access by patients. This should be away from the clinical
area and bedrooms;
Personal goods store should be accessible to patients and adjacent
to bed areas;
Patient’s laundry should be distant to the bedrooms, interview rooms
and social/activity/therapy area;
Clean Utility, interview rooms, Charge Nurse office and
social/activity/therapy area should be clustered together and distant
from the bedrooms and hotel services area;
The bedrooms should be distant from the hotel services and clinical
areas; and
The female only day room should be sited in accordance with the
mixed sex guidance.
Fitness Suite clustered with day areas and distant to bedrooms
Storage facilities
196
The following storage facilities are required for:
•
•
•
•
•
Clinical equipment such as moving and handling equipment;
Patient personal possessions that are not stored in their own room;
Flat linen and towels;
Spare duvets, pillows and mattresses; and
Miscellaneous items.
Anticipated developments
As already described the building is being designed with the ability to
become a Low Secure Unit should that become the prevalent need;
The building should be flexible in design to meet the challenges of an
ever changing and improving Health Service; and
The building should be able to meet the needs of future Information
Technology developments.
Client Group Characteristics
Age and Gender
18 to 64 years old, male and female
Admission Rates
Admissions are accepted 365 days per year, 24 hours per day,
following assessment, but will be infrequent and planned
Diagnoses
Clients admitted to the ward suffer from an identifiable mental disorder
Anticipated illness-related behaviours
Clients who are admitted to this ward may display the following;
Disinhibited behaviours;
197
Unpredictable and impulsive behaviours;
Aimless or ritualistic behaviours;
Lack of personal risk awareness;
Determined attempts to abscond; and
Drug / Alcohol seeking behaviour.
Anticipated clinical risks
Clients who are admitted to this ward may be at risk from the following:
Deliberate self harm;
Harm to others;
Self neglect;
Suicidal intention;
Poor mobility;
Poor motivation;
Absconding;
Drug / Alcohol use;
•
•
Isolation in a community environment (social breakdown); and
Institutionalisation
Patient dependency characteristics
Therapeutic Intent
Principal aims of clinical care
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•
•
In-patient care is one element of the care pathway. It offers time
limited safety, support and therapy to people who are too unwell
to be cared for in less secure surroundings;
Offer systematically organised, personally tailored collaborative
help, treatment and care in an atmosphere of hope and
optimism.
To provide individualised care to people experiencing mental
illness who require a period of rehabilitation to facilitate a return
to independent or supported community living;
To work collaboratively with the individual to improve their mental
and physical health and functioning and social interaction;
Is not to be respite from other elements of the care pathway; and
Is to provide a stepping stone to inclusion, not a departure point
for exclusion.
Therapies
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•
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•
•
A collaborative approach to care will be embraced in that the
care team will encourage the individual to take an active role
(and preferably lead) in their recovery by encouraging them to
agree their activity programme from the range of therapeutic
activities/interventions available to them within the Unit, the wider
hospital setting and as quickly as possible in their local
communities.
Individual and group therapies will be provided in an appropriate
setting within and out-with the facility in accordance with an
individualised care plan;
Activities will be designed to address a spectrum of health and
social care needs, which typically include physical, psychological,
recreational, life-skill, cultural, spiritual and social elements.
Therapies will enhance the care experience and will be focussed
upon specific agreed interventions and outcomes;
A key aim will be to provide a platform for social inclusion by reintegrating the patient into what will be their local community on
discharge and local services. Working towards independence
and discharge will be the underpinning objective at all times;
Wherever possible service users will be encouraged to self cater
in some way, whether it is making a cup of tea and a snack
through to fully self-catering all meals; and
Therapies should be in keeping with the Recovery/Tidal model
and be evidence based.
Therapeutic facilities required
Adequate space to provide therapeutic interventions as required within
the ward and Support Cluster 2; and
Adequate storage space to contain therapeutic equipment will be
required within the ward, recreational facility and Support Cluster 2.
Planned clinical meetings
Adequate space is required to provide for a variety of clinical meetings
which will take place on a daily basis
Nursing handover reports
Multi-disciplinary meetings
Consultant Meeting
Junior Doctor Reviews
CPA Meetings
Case Conferences
One to one clinical interventions
Group Treatment
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Other Meetings
Meetings with relatives
Meetings with extended care team
Educational meetings
Appraisal meetings
Staff meetings
Ward community meetings
Clinical risk management principles
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Robust risk assessment on admission to include period of time
with no unescorted time off of ward;
Based on a proactive approach to positive risk management
(embedded within the service);
Approach to care will be collaborative and will attempt to support
the individual to retain control over their actions and treatment
plan wherever possible;
Unit will be an open Unit (when FRU) and individuals will be
individually managed to minimise impact on fellows should there
be restrictions to their movement as per risk assessment and
management plan;
Be cognisant of Memorandum of Procedure (MOP) with regards
to Management of Restricted Patients and notifiable events
http://scotland.gov.uk/Publications/2010/06/04095331/0
Formalised assessment tools within FACE will be utilised and
process reviewed on an ongoing individualised basis;
Additional formalised tools such as CHR20 and START will be
utilised to assist in risk assessment;
Environment will be anti-ligature in nature; and
Admissions will be planned in nature and subject to meeting
acceptance criteria and potential risk issues being manageable
within the Unit
Operational Procedures
Working day plans
The wards will be open 365 days per year and 24 hours per day
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Staffing arrangements and shift patterns
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•
•
The wards will be staffed 365 days per year and 24 hours per
day
Staffing levels and shift patterns will be set out to achieve the
optimum level of therapeutic care in a safe and secure setting
Wherever possible individuals will be supported to undertake
rehabilitative activity in their local community which may place a
demand on the staff group if travelling to Ayr for example
Admission procedures
Admissions and transfers will be on a planned basis.
Record-keeping storage
A paper light system will be utilised but all clinical case records require
to be stored within a lockable cabinet within a lockable room –
electronic record keeping will minimise the requirement for stored
records
Items of secure stationery require to be stored within a lockable cabinet
Visiting arrangements
Patients will receive visitors in an interview room on a planned basis
Children may only visit the Unit with explicit approval of RMO
Visiting must not interfere with planned programmes of care and will be
planned as part of the activity programme for an individual.
If the patients condition and parole status allows, they can accompany
visitors to the café area in the main entrance
Mealtimes/dining arrangements
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Dining arrangements will require to be flexible and provide
healthy eating options and between meal snacks and access to
beverages available
Facilities must promote the ambiance of the meal experience
It is hoped that the majority of individuals will self cater with the
majority fully self-catering, the requirement for a large ADL
kitchen reflecting this (will not be the case if Low Secure and this
area will require to be locked off) & a dining room with sit down
provision of meals will be needed
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Between meal snacks and access to beverages
Facilities will be available within the pantry area to allow between meal
snacks and access to beverages
Laundry facilities and linen management
A room is required to provide for washing, drying and ironing of
personal clothing which should be accessible to patients.
Functional content
Number of Inpatient Beds/Treatment Spaces
•
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•
8 beds (in patients)
Access to interview rooms and meeting rooms
Two social/activity/therapy areas which can be opened up to larger
area
In the future there would be a distinct advantage if the community forensic
team, remaining at Ailsa Hospital at this time, could be provided for at
North Ayrshire Community Hospital. It would be preferable for this
accommodation to be located as close to the forensic rehabilitation unit,
given their joint working arrangements, with the intention of strengthening
the relationships of all the relevant care teams and strengthen the
integrated care pathway and links between health and Criminal Justice
System.
Investigative/Diagnostic/Treatment Capacity:
Will require to be accessed at nearest General Hospital and other
specialist services as required.
Outpatient Service (Number of Sessions and
specialist functions):
•
Will provide outreach service to some individuals on discharge for a
time.
Specialist Technical Infrastructure Requirements
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Telephones for internal and external communications;
IT Systems for recording patient information electronically e.g. FACE;
System that have PC Pens and Tablets for utilisation by service users to
participate in care planning etc;
PIN point system alarms;
Nurse Call System;
Slow Door Systems;
Emergency alerts for Immediate Response Team;
Mobile phones for escort duties;
Portable oxygen cylinders;
Security Entry out of hours – intercom at entrance to wards;
ECG machine
Projected Future Activity
The service will work to:
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The principles outlined in the Mental Health (Care and Treatment)
(Scotland) Act 2003
Other appropriate legislation and Scottish Executive guidance.
These can be summarised as:
Participation of the patient in the process;
Respect for carers including consideration of their views and
needs;
The use of informal care wherever possible;
The use of the least restrictive alternative;
The need to provide the maximum benefit to the patient;
Non-discrimination against a mentally disordered person;
Respect for diversity regardless of a patient’s abilities, background
and characteristics;
Reciprocity in terms of service provision for those subject to the
Act;
The welfare for any child with a mental disorder being considered
paramount; and
Equality.
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Key Relationships with Other Departments/NHS
Ayrshire and Arran /Social Services/Social
Work/Local Authority Services
Close to
Rehabilitation Unit
Reason
Category*
Essential
• Accessing group
activity
programme
in
their area.
• Staff support
IPCU
• Ease of transfer Essential
• Safety alerts
• Extra staff
• Patient privacy
Desirable
• Acute Admission Staff support.
Wards
Community Mental
Health Team (Forensic)
•
•
Access to ANP staff
Close to ambulance
entrance
•
•
•
•
•
Support Cluster 2
•
•
•
•
To
facilitate Essential
communication
re
discharge
planning.
Minimise travel
time.
Essential
Rapid response
24
hours/day
response
Delivery
of Essential
Ambulance
Services
Reliance
Vehicles
Ease of access Essential
for inpatients
Safety
Staff assistance
Accessible
for
visiting agencies
Future Service Delivery Risks
Future client requirements & activity unclear and unpredictable;
Initial staffing numbers would require to be significantly enhanced if to
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become Low Secure Unit with associated costs;
May be temptation to accept clients with higher risk issues rather than place
in private sector Low Secure provision to keep within NHS Ayrshire & Arran;
Delayed discharges due to tenancy issues or options available within Local
Authority to support discharge;
Stagnation due to lack of community services to move people on to
(especially re Housing requirements);
‘Split’ of client group may change with more disturbed individuals requiring
greater support and intervention by staff with impact on staffing resource
and challenge to maintain programmes of activity;
•
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•
•
•
•
•
•
•
Implication of unknown long term drug abuse;
Continuity & sustainability.
Changing nature of clientele and therefore need to become Low
Secure Unit within existing environment.
Fit with integrated care pathways.
Health & Safety (anti-ligature)
Recreation, diversion/rehab activities
Resources
Throughput activity/case mix change
Proximity of local resources re rehabilitation of patients
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Appendix P - Rehabilitation Unit (Adult Mental
Health)
Introduction and outline of services
Departmental Function
Overview
To provide an environment and culture that supports the provision of
individualised rehabilitative programmes of care to individuals experiencing
and recovering from a mental illness. This mental illness will typically have
had an impact in their ability to function independently in the community and
to cope with the requirements of everyday living. They may have become
de-skilled as a result of prolonged mental ill-health, extended hospital stay,
self neglect, lack of support or ability to cope with the activities of daily living.
The Unit will cater for a variety of individuals – supporting individuals who are
perhaps treatment resistant and who require a longer period of care than can
be facilitated in an acute admissions setting with active positive symptoms
through to individuals whose illness may be very well controlled but who
require to develop confidence in skills in undertaking daily living skills such
as budgeting, maintaining a home, shopping, cooking. In the initial term the
Unit may also have to cater for individuals who are in fact unlikely to be
discharged from NHS 24 hour care and who will require to be supported in
most tasks by staff – it is anticipated that the majority of these individuals will
be supported on Ailsa campus however as they will have been a patient in
Ailsa for a protracted period of time.
The Unit as a whole will embrace a Recovery Approach, ‘recovery’ defined
by William Anthony as being
‘a way of living a satisfying, hopeful and contributing life even with the
limitations caused by illness. Recovery involves the development of a new
purpose and meaning in one’s life as one grows beyond the catastrophic
effects of mental illness’. Anthony, W.A. (1993)
In order to better describe how the different broad needs of clients within the
Rehabilitation Unit will be met these needs can be broadly described in three
sub-divided streams:
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Stream 1: Those individuals with enduring needs who may require a slower
paced programme of care designed to maximize their potential whilst
acknowledging the likelihood that they will require prolonged support either in
a hospital setting or in an intensively supported community setting.
Stream 2: Those individuals with ongoing needs and skills deficits who have
been identified as being likely to respond to a medium paced rehabilitation
programme designed to maximize their ability to function with a degree of
independence with moderate support within a care or community setting.
1
Stream 3: Those patients with clearly identified needs likely to respond to an
intensive fast-paced rehabilitation programme aimed at supporting them to
develop their skills to a level where they can function within the general
community either independently or with minimum support.
Individuals will be able to move up and down streams dependent on their
needs. There will also be a level of flexibility allowing patients who fall
predominately within one stream to access components of other streams.
This level of flexibility will be reflected in the physical structure of the ward.
•
• Teams and Links
•
The Rehabilitation Unit will be managed by nursing staff working within a
person-centred, multi-disciplinary and multi-agency framework in partnership
with, physiotherapy, dietetics, occupational therapy, speech & language
therapy, advocacy, social work, advanced nurse practitioners, psychology,
medical staff and a range of visiting support services. Efforts will be made,
wherever possible, to engage with all agencies involved with an individual
prior to transfer/admission to the Unit to ensure a holistic approach to care,
avoid duplication of effort and ensure engagement with the significant others
of an individual.
Where agreed with the individual this will include relevant parties being
invited to Multi-Disciplinary Meetings including MDT Reviews, Care
Programme Approach meetings, Pre-Discharge Meetings, case conferences
etc. Further links exist with the University of West of Scotland (Nurse
Training) and the Royal College of Psychiatrists (Medical Training).
2
At any given time there could be up to 12 nursing staff on duty across the
Unit working within the ‘wings’ and the larger therapeutic area (variable with
clinical demand), this could be supplemented by up to 4 student nurses.
When the number of Medical staff (Consultants, Junior Doctors and
Trainees), Allied Health Professionals and representatives of other agencies
are added to this it is possible that up to 20 staff may be present and will
require to be accommodated on the Unit at peak times.
As part of the “Hospital at Night Service”, the development of the Advanced
Nurse Practitioner role will provide cover at night which was previously
provided by junior medical staff.
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Service Users
Although this is an adult admission area, both the accommodation and
delivery of care needs to be flexible enough meet the needs of people with a
range of ages and can include those who may have a physical disability
and/or mild learning difficulties.
Admissions will be accepted from a variety of sources including Acute
admission wards, Forensic Rehabilitation Unit, and Community referrals.
Patients will be admitted primarily as a result of a mental health problem
which has prevented them achieving and/or led to a deficit in their ability to
maintain a safe, independent lifestyle in the community.
There are also a small group of patients who need ongoing longer term NHS
continuing health care. These patients need ongoing and regular specialist
clinical supervision as a result of the complexity, nature or intensity of their
health needs. They require frequent, not easily predictable, clinical
interventions which can be as a result of rapidly degenerating or unstable
condition which requires specialist medical and nursing supervision. It is
anticipated the majority of such patients will be supported on Ailsa campus.
3
They may also have physical symptoms, which may be due to:
a co-morbidity of disease , because of dependence on drugs and/or alcohol
or
as a result of the lifestyle choices made by some people with severe and
enduring mental illnesses leading to a lack of social skills and self neglect
with a subsequent and often significant deterioration in their state of physical
well-being.
During the individual’s stay they will be encouraged to maintain and foster
relationships with significant others in the community and as such may be
regularly visited by family, relatives and friends who will also be encouraged
to participate in and support the person’s plan of care and participate in the
person’s recovery process.
Therapies and Treatment.
A collaborative approach to care will be embraced in that the care team will
encourage the individual to take an active role (and preferably lead) in their
recovery by encouraging them to agree their activity programme from the
range of therapeutic activities/interventions available to them within the Unit,
208
the wider hospital setting and in their local communities.
Elements from the ‘Treatment Mall’ model (Bopp, Riddle, Cassidy, & Markoff,
1996) commonly utilised in America will be adopted – namely that there will
be a dedicated space within the Unit where specific sessions will be available
to the patient group (also to those not within the Rehabilitation Unit) that will
be delivered by a variety of staff such as Pharmacists, AHPs, Psychologists,
external Lecturers, Nursing Staff, Addiction Services staff etc and that
individuals will incorporate into their individual activity programme in addition
to one-to-one time spent with their key worker or closed group sessions
within their sub-units. Dedicated and ‘bookable’ space will be required within
the unit to allow the facilitation of this programme of activity and the spaces
will require to be flexible with the option to open up dividing walls/partitions to
allow for larger groups should that be required or social activity.
Meaningful activity will be vital within the Unit and this will require to be
supported by a comprehensive ongoing assessment. Activity will largely be
scheduled and will be co-ordinated and provided on a multi-disciplinary basis
that will directly involve the individual and their carer as a key part of the
team.
Activities will be designed to address a spectrum of health and social care
needs, which typically include physical, psychological, recreational, life-skill,
cultural, spiritual and social elements.
4
Each person will be engaged in the creation of an individualised activity plan
that will be the keystone to their journey of recovery and will reflect their
needs, wishes and aspirations and is cognisant of their capabilities.
A key aim will be to provide a platform for social inclusion by re-integrating
the patient into what will be their local community on discharge and local
services. Working towards independence and discharge will be the
underpinning objective at all times.
Effective integrated working and communication with community based
health services and other agencies will be a key service element.
Some individual therapies including patient consultations, psychological
therapies and advanced psychiatric assessments, will require private,
confidential space (significant sound insulation whilst not compromising
safety), allowing individuals the opportunity to express their emotions and
personal issues.
Wherever possible service users will be encouraged to self cater in some
way, whether it is making a cup of tea and a snack through to fully self209
catering all meals.
Space and Observation.
The feeling of space plays a key role in promoting recovery and, as such, it is
of the utmost importance that all residents have access to private and
communal space both internally, in the form of small quiet areas and
externally in the form of significant, safe therapeutic green space. Within the
30-bedded unit there should be sub-units that allows individuals the
opportunity to spend time in areas that are potentially only occupied by 8-10
but no greater than 15 people and therefore are quieter and allow an
individual to take time out from others and have an area other than their
bedroom that they perceive as theirs.
5
Some behaviours, for instance behaviours associated with self harm, and
elevated mood may compromise an individual’s safety, increasing personal
risk. Therefore there is a requirement to have the ability to facilitate a high
level of awareness/supervision and observation of patients who are acutely
unwell, in an appropriate environment i.e. in a sub-unit of the larger overall
unit.
Individuals will be encouraged to not spend large amounts of time in their
bedroom during the day but be in day spaces or out in the grounds or
community engaged in meaningful activity as per their individual programme,
thereby reducing the requirement for staff to be able to observe the unit as a
whole at all times. Similarly at night the residents will be encouraged to be in
their sub units, each of which will have sitting rooms and a snack kitchen
which will allow staff to not be required to observe the larger day/therapy
area as it will be locked off and unoccupied.
The preferred layout for the unit would be 3x10-bedded sub-units within the
overall unit, by design it would be useful if these 3 bedroom areas could be
observed from 2 staff bases overnight, thereby reducing the number of staff
required to facilitate adequate supervision overnight
It is envisaged that on any given day a number of individuals will be engaged
in therapeutic activity out-with the Unit and Hospital setting, accessing
therapies and services within their local Community. This will reduce the
number of people in the Unit but will have a requirement that staff are able to
be released to support activity out with the Unit setting whilst maintaining
reasonable numbers in the Unit to facilitate activity and ensure a safe
environment.
Legislation & Governance
We are governed by legislation which directs us to provide practical solutions
210
for patient safety and also the principles under the Mental Health (Care and
Treatment) (Scotland) Act 2003:
Non-discrimination - people with a mental disorder should, wherever
possible, retain the same rights and entitlements as those with other health
needs.
Equality - all powers under the Act should be exercised without any direct or
indirect discrimination on the grounds of physical disability, age, gender,
sexual orientation, language, religion or national, ethnic or social origin.
Respect for diversity - service users should receive care, treatment and
support in a manner that accords respect for their individual qualities, abilities
and diverse backgrounds and properly takes into account their age, gender,
sexual orientation, ethnic group and social, cultural and religious
background.
Reciprocity - where society imposes an obligation on an individual to comply
with a programme of treatment and care, it should impose a parallel
obligation on the health and social care authorities to provide safe and
appropriate services, including ongoing care following discharge from
compulsion.
Informal care - wherever possible care, treatment and support should be
provided to people with mental disorder without recourse to compulsion.
Participation - service users should be fully involved, to the extent permitted
by their individual capacity, in all aspects of their assessment, care,
treatment and support. Account should be taken of both past and present
wishes, so far as they can be ascertained. Service users should be provided
with all the information and support necessary to enable them to participate
fully. All such information should be provided in a way which renders it most
likely to be understood.
Respect for carers - those who provide care to service users on an informal
basis should receive respect for their role and experience, receive
appropriate information and advice, and have their views and needs taken
into account.
Least restrictive alternative - service users should be provided with any
necessary care, treatment and support both in the least invasive manner and
in the least restrictive manner and environment compatible with the delivery
of safe, effective care, taking account where appropriate of the safety of
others.
211
Benefit - any intervention under the Act should be likely to produce for the
service user a benefit which cannot reasonably be achieved other than by
the intervention.
Child welfare - the welfare of a child with mental disorder should be
paramount in any interventions imposed on the child under the Act.
Schedule of Accommodation
The accommodation is scheduled in Mental Health Services and is described
in the section rehabilitation in-patient accommodation in the Schedule of
Accommodation.
Model of Care
Descriptive Overview
The objective of this rehabilitative clinical service will be to provide and/or
facilitate access to a range of therapeutic and social interventions, which are
planned, co-ordinated and provide a multi-disciplinary and user/carer
perspective, based on comprehensive ongoing assessment. A key aim will
be to provide a platform for social inclusion, not a stepping stone to
exclusion. The Unit will aim to offer systematically organised, personally
tailored collaborative help, treatment and care in an atmosphere of hope and
optimism.
Whilst the Unit as a whole will encompass thirty beds an individual’s bed
location will not define their programme of care, rather the configuration of
the accommodation will allow the opportunity for some separation dependent
on diagnosis, identified risk and potentially to some extent by at which stage
in a programme of care the individual is. This would allow potentially
vulnerable females to be managed in separate areas from a disinhibited
male for example.
It is widely accepted that the recovery process is non-linear (Strauss and
colleagues 1985) but that there are stages of change, Davidson, Roe,
Andres-Hyman and Ridgway (2010) describe in their ‘Transtheoretical Model’
five stages of change –
Precontemplation (or pre-recovery)
Contemplation
Preparation
212
Action
Living beyond Disability (formerly described as maintenance)
There will therefore require to be a real flexibility around the programme of
activity and engagement and that the bedroom and sub-unit an individual
sleeps in does not define what activities and therapies they can engage in as
they may move up and down through these stages.
Each person will be engaged in the creation of an individualised activity plan
that will be the keystone to their journey of recovery and will reflect their
needs, wishes and aspirations and is cognisant of their capabilities.
A key aim will be to provide a platform for social inclusion by re-integrating
the patient into what will be their local community on discharge and local
services. Working towards independence and discharge will be the
underpinning objective at all times.
Effective integrated working and communication with community based
health services and other agencies will be a key service element.
The care environment should:
Create a calm and restful atmosphere and an environment which is nonthreatening;
Allow the support and observation of clients who may still be quite acutely
unwell or suffering from a relapse of their condition in an appropriate
environment whilst protecting their dignity and well-being;
Maximise therapeutic opportunities and the ability to relieve boredom;
Afford no undue separation of staff from patients;
Be attractive, uplifting and interesting in terms of décor, fabric, furnishings
and interior and exterior design, as well as the use of natural materials,
colour and textures;
Create a feeling of well ventilated space, maximising the use of natural light
and minimising the reliance on artificial light;
Garden areas should be designed to provide contrasting textures and
colours of plants, providing sensory stimulation and promoting sense of calm
and relaxation. There should also be sheltered areas, suntraps and
comfortable seating within the overall design.
Provide opportunities for exercise, leisure and education; and
Be sensitive to the needs of physically disabled patients, visitors and staff.
The overall environment within the Unit should be conducive to providing
individualised care within a safe, therapeutic setting to enable recovery
focussed, person centred care. The emphasis will be on programmes of care
213
that support activities of daily living and promotion of independent living.
Access to and utilisation of green spaces will be vital.
Certain parts of the programmes of activity/therapy facilitated within the Unit
will not be exclusively for those resident in the unit, for instance, if a
Pharmacist was delivering a session on medications, their effects and sideeffects then this should also be available to individuals in the acute setting.
The use of the facilitates within the support cluster will be vital also – Fitness
Suite, ADL kitchen, Consulting Rooms that will be used to facilitate groups.
A key element will be to support and enhance social interaction and self
care. There will be a need to maintain or develop close links near to the
person’s own or future tenancy and community as part of the rehabilitative
and discharge process. Ensuring integration within community support
networks through employment, enablement and recreational/leisure near to
their area of residence on discharge.
Role and Function
Care will be person centred and collaborative in nature;
Informed by an understanding of the psychological principles governing how
people can learn to change;
Services must respect the individual;
Services must offer privacy and dignity;
Activity will not be solely within the Unit but much will be community based in
supporting and guiding people to access their local services on discharge;
The Unit will offer access to a resource in addition to those individuals
resident in the unit;
Services must balance the need for safety and security with the provision of
a therapeutic environment;
The environment requires to lend itself to obtrusive and unobtrusive
observation; and
The environment must be pleasant, safe and the general ambience promote
mental health well being.
Bed complement
30 beds provided in single room accommodation with en-suite facilities –
these single bedrooms should be preferably be configured in 3 separate
wings or sub-units. Each sub-unit should have the ability to be reasonably
self-contained in having sitting areas, snack kitchen, interview rooms etc but
214
utilise the larger communal space for the bulk of planned activity
The service should be able to be developed and flexibility of beds for future
service trends is vital which having the ability to sub-divide would facilitate
If 3 x 10-bedded wings then bed provision will likely be gender specific in two
of the sub-units and possibly mixed sex in the third dependent on the needs
at any given time.
Planned patient activity
Admissions will be accepted from a variety of sources such as;
•
•
•
Acute wards
Forensic Rehabilitation Unit
Community referrals
Usual admissions to this area will represent clients whose needs include;
•
•
•
•
•
•
•
•
•
•
Social integration needs to be developed;
Mental disorder has led to the breakdown of their social
infrastructure/support;
Complexity, nature or intensity of their mental health needs (overall
medical, nursing and other clinical needs) require NHS 24 hour care
beyond that which can normally be met in the acute setting;
Mental health needs require frequent, not easily predictable, clinical
interventions;
Require a focussed programme of rehabilitative skilling and/or reskilling to address deficits in activities of daily living;
Have potentially become institutionalised due to lengthy in-patient
episode of care
Require assistance to develop skills to maintain/obtain tenancy;
Require assessment to identify/secure appropriate package of support
to facilitate discharge;
Meet physical well-being requirements and access to physical
exercise etc; and
Build up social, community networks and support to maintain
independence and have the best chance of succeeding.
General principles of operation
•
•
•
All clinical, therapeutic and social care will be provided at the least
restrictive level appropriate to the needs of the service user group and
should become community based as quickly as possible;
Clinical interventions will be evidence based and reflect current best
practice;
Intervention will be provided in keeping with an individual’s
collaboratively developed care plan, utilising a person centred
215
•
•
approach;
The focus will be on meaningful and therapeutic activity based on
holistic assessment both within and out-with the Unit, and
The longer duration of stay should be reflected in the investment in
the environment and facilities
Design Synopsis
In addition to the core design synopsis/critical features, unique features to
this environment will be;
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Doors, locks and windows should be of a design which is antibarricade and enables access by staff in an emergency;
Maximum use of natural and artificial light;
Maximum use of natural and artificial ventilation;
Discreet hotel and storage services;
Dining facilities that enhance the meal experience;
Significant facilities that facilitate self-catering activity;
Clinical areas that are non threatening and welcoming;
Bedroom areas should enhance the therapeutic experience and also
provide privacy, each bedroom to have a safe or lockable drawer to
allow safe storage for self-medication;
There should be the ability to observe as many of the bedrooms as
possible from one point overnight
All public areas within the ward should be easily observable with no
blind spots;
Significant dedicated outside space accessed from public areas of
the Unit;
Therapy/activity rooms within the main public area of the unit that are
utilised in the delivery of programmes of activity;
There should be one single point of entry to the larger unit, with the
ability to close off sub-units at night and if required at other times;
Ligature points should be eliminated;
Appropriate access to sheltered designated smoking area - out of
doors; and
Emphasis on space requirement should be on day areas rather than
bedrooms.
Corridors: Required features
Corridor area should be kept to a minimum;
Corridors should have no blind spots and allow maximum observation;
Where corridors are not just to get from A to B they should have the
opportunity for informal social contact, non institutional and natural light; and
Corridors should provide seated areas for quiet contemplation.
216
Mixed gender requirements
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
The design of the facility must comply with current legislation
The building should be sensitive to the needs of physical and sensory
disabled patients, staff and visitors.
Privacy and dignity requirements
The design of the unit must comply with current legislation
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
•
•
•
The unit should be self-contained but adjacent to other adult inpatient areas and connected by Support Cluster 2;
The unit should have access to private communal safe, stimulating
and landscaped and sheltered garden areas to gain access to fresh
air without compromising safety, privacy or dignity; and
Close proximity to Support Cluster 2 (link corridor/walkway
undercover);
Internal
•
•
•
The larger public and therapy rooms should be the hub of the Unit off
which the sub-units radiate and these should be largely selfcontained, the bedrooms being distal to the hub
Clean and Dirty utility rooms and store room should be away from the
main clinical areas;
Consultation and therapy rooms should be distant from the
217
•
•
•
•
bedrooms;
The bedrooms should be distant from the clean and dirty utility room,
store room, interview room, staff base and open plan areas;
Individual patient bedrooms should be lockable using locks that can
be over-ridden by staff;
The staff base for 3 staff should be at the main unit entrance; and
The Charge Nurse office should not be at the main entrance to the
ward but ideally within the main ‘hub’.
Storage facilities
The following storage facilities are required for:
Access to equipment store for all apartments as required
Flat linen and towels
Miscellaneous items
Mobility aids as required
Central patient personal possessions that are not stored in their own room
Range of seasonal equipment (e.g. Christmas decorations)
Spare duvets, pillows and mattresses
Therapeutic equipment
Miscellaneous items
Anticipated developments
The building should be able to meet the needs of future Information
Technology developments;
The building should be flexible in design to meet the challenges of an ever
changing and improving Health Service; and
Utilisation of smart technologies and alarm systems should be integrated
from outset.
Client Group Characteristics
Age and Gender
18 - 64 years male and female although there will be some discretion re
those of an older age who may still have contact with ‘adult’ services
Admission Rates
218
Admissions will be via planned transfer and following assessment and
acceptance criteria being met
Diagnoses
Clients admitted to the Unit will have a varying range of mental health
problems/illness and may experience issues re drug/alcohol misuse
Anticipated illness-related behaviours
Clients who are admitted to the Unit may display the following:
•
•
•
•
•
•
•
Aggressive behaviour (verbal and physical)
Aimless or ritualistic behaviours
Disinhibited behaviours
Lack of personal risk awareness
Engage in challenging behaviours – deliberate self harm, absconding,
use of alcohol or non-prescribed substances
Unpredictable and impulsive behaviours due to active psychotic
symptoms
Behaviours associated with negative symptoms of longer term mental
illness – lacking in motivation and confidence
Anticipated clinical risks
Clients who are admitted to this ward may be at risk from the following
• Deliberate self harm
• Harm to others
• Absconding
• Poor mobility
• Poor motivation
• Self neglect
• Suicidal intention
• Isolation in a community environment (social breakdown)
Institutionalisation
Patient dependency characteristics
•
•
•
•
•
Poor physical health and associated mobility problems;
Institutionalisation;
Negative symptoms associated with enduring, longer term mental
illness;
Level of functioning and ability to do everyday tasks reduced (selfhelp compromised);
Treatment resistant; and
219
•
Communication issues.
Therapeutic Intent
Principal aims of clinical care
•
•
•
•
•
Offer systematically organised, personally tailored collaborative help,
treatment and care in an atmosphere of hope and optimism.
To provide individualised care to people experiencing mental illness
who require a period of rehabilitation to facilitate a return to
independent or supported community living;
To work collaboratively with the individual to improve their mental and
physical health and functioning and social interaction;
Maximising person’s level of independence; and
To minimise the time spent in the in-patient setting by providing a
comprehensive outreach function to assist in returning individual to
the community more rapidly.
Therapies
•
•
•
•
•
•
•
A collaborative approach to care will be embraced in that the care
team will encourage the individual to take an active role (and
preferably lead) in their recovery by encouraging them to agree their
activity
programme
from
the
range
of
therapeutic
activities/interventions available to them within the Unit, the wider
hospital setting and in their local communities.
Individual and group therapies will be provided in an appropriate
setting within and out with the facility in accordance with an
individualised care plan;
Activities will be designed to address a spectrum of health and social
care needs, which typically include physical, psychological,
recreational, life-skill, cultural, spiritual and social elements.
Therapies will enhance the care experience and will be focussed
upon specific agreed interventions and outcomes;
A key aim will be to provide a platform for social inclusion by reintegrating the patient into what will be their local community on
discharge and local services. Working towards independence and
discharge will be the underpinning objective at all times;
Wherever possible service users will be encouraged to self cater in
some way, whether it is making a cup of tea and a snack through to
fully self-catering all meals; and
Therapies should be in keeping with the Recovery/Tidal model and
be evidence based.
220
Therapeutic facilities required
•
•
Adequate space to provide therapeutic interventions as described
within the ‘Numbers and Types of Rooms’ and within the schedule of
accommodation, due to the function of the Unit these areas are the
focus of the environment
Adequate storage space to contain therapeutic equipment will be
required within the units.
Planned clinical meetings
•
•
•
•
•
•
•
•
•
Adequate space is required to provide for a variety of clinical
meetings which will take place on a daily basis
Access to Tribunal accommodation to comply with Mental Health Act
Nursing handover reports
Multi-disciplinary meetings
Consultant meeting
Junior Doctor reviews
CPA meetings
Case conferences
Clinical interventions
Other Meetings
•
There will require to be the facility for community meetings which may
include potentially all 30 residents or be within the sub-units. The
open plan hub area should be able to accommodate such a meeting.
Clinical risk management principles
•
•
•
•
•
•
Based on a proactive approach to positive risk management
(embedded within the service);
Approach to care will be collaborative and will attempt to support the
individual to retain control over their actions and treatment plan
wherever possible;
Unit will be an open Unit and individual’s will be individually managed
to minimise impact on fellows should there be restrictions to their
movement as per risk assessment and management plan;
Close adjacencies to other AMH wards and IPCU will provide support
for staff in case of emergency situations and allow transfer of an
individual should the identified risk require this;
Formalised assessment tools within FACE will be utilised and process
reviewed on an ongoing individualised basis;
Environment will be anti-ligature in nature; and
221
•
Admissions will be planned in nature and subject to meeting
acceptance criteria and potential risk issues being manageable within
the Unit
Operational Procedures
Working day plans
The unit will be open 365 days per year and 24 hours per day
Staffing arrangements and shift patterns
•
•
•
•
Multidisciplinary team handovers will take place at set times
throughout the day as determined by the ward team;
The unit will be staffed 365 days per year and 24 hours per day and
will provide an outreach service to those in process of phased
discharge;
Unit will assist in assessment/advice of individuals in other care
settings with regards to rehabilitative opportunities and offer the
ability for individuals from other areas to attend and participate in
activities within the unit; and
Staffing levels and shift patterns will be set out to achieve the
optimum level of therapeutic care in a safe and secure setting.
Admission procedures
Admissions will be via planned transfer and following assessment and
satisfaction that admission criteria are met
Record-keeping storage
•
•
•
•
•
A paper light system will be utilised but all clinical case records
require to be stored within a lockable cabinet within a lockable room –
electronic record keeping will minimise the requirement for stored
records
Items of secure stationery require to be stored within a lockable
cabinet
Visiting arrangements
Visiting arrangements will be as agreed with the unit team and may
take place within the dining area or consultation rooms within the Unit
or out with. Visiting should not interfere with planned programmes of
care and ideally should be planned as part of the activity programme
for an individual.
Children visiting should be planned in advance and in agreed areas
of the Unit.
222
Mealtimes/dining arrangements
Dining arrangements will require to be flexible and provide healthy eating
options and between meal snacks and access to beverages available
Facilities must promote the ambiance of the meal experience
It is hoped that the majority of individuals will self cater in some way with the
hope that those nearing discharge will be fully self-catering, the requirement
for a number of ADL kitchens and sitting areas reflecting this
Between meal snacks and access to beverages
There will be a larger ADL kitchen in the hub with snack and beverage
preparation areas in each of the sub-units.
Laundry facilities and linen management
There will be a personal laundry facility in each sub unit to allow individuals
to launder and iron their clothes.
Bed linen will be provided from hospital stock and laundered by NHS
facilities
Functional content
Number of Inpatient Beds/Treatment Spaces
30 in total, 27 single bedrooms, 3 larger bedrooms, one in each sub-unit.
Investigative/Diagnostic/Treatment Capacity:
If not available onsite will require to be accessed at nearest General
Hospital and other specialist services as required.
Outpatient Service (Number of Sessions and
specialist functions):
Will provide outreach support for a time on discharge to ease transition.
Individuals non-resident in the Unit will be afforded the opportunity to
participate in planned activity.therapy sessions as agreed appropriate with
their care team.
223
Specialist Technical Infrastructure Requirements
•
•
•
•
•
•
•
•
•
•
•
•
Telephones for internal and external communications;
IT Systems for recording patient information electronically e.g. FACE;
System that have PC Pens and Tablets for utilisation by service users
to participate in care planning etc;
PIN point system alarms;
Nurse Call System;
Slow Door Systems;
Emergency alerts for Immediate Response Team;
Mobile phones for escort duties;
Portable oxygen cylinders;
Security Entry out of hours – intercom at entrance to wards;
ECG machine; and
Emergency Medication Box for escort duties.
Projected Future Activity
By encompassing the historical ‘non-acute’ function with the intensive
rehabilitative model then it is anticipated that the unit should run at
approaching 100% occupancy.
The model of care will be reviewed and updated to reflect modern mental
health approaches to rehabilitation services and current evidence based
practices and latest research
224
Key Relationships with Other Departments/NHS
Ayrshire and Arran /Social Services/Social
Work/Local Authority Services
Close to
Pharmacy
Therapies service
Public transport
•
•
•
•
Leisure and social
facilities
•
Acute Wards
•
IPCU
•
Community Mental
Health Teams
•
Support Cluster 2
•
•
•
•
Reason
Advice, supplies
and education
Ease of access
Engagement
Mobility
and
rehabilitation
Part of daily living
programme, social
inclusion
Source of referral,
staff
support.
Access if requiring
to
transfer
disturbed
individual.
Access if requiring
to
transfer
disturbed
individual.
To
facilitate
communication re
discharge
planning
Ease of access for
inpatients
Safety
Staff assistance
Accessible
for
visiting agencies
Category*
Essential
Essential
Essential
Essential
Essential
Essential
Desirable
Essential
•
225
Future Service Delivery Risks
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Future client requirements & activity unclear and unpredictable;
Delayed discharges due to tenancy issues or options available within
Local Authority to support discharge;
Stagnation due to lack of community services to move people on to
(especially re Housing requirements);
‘Split’ of client group may change with more disturbed individuals
requiring greater support and intervention by staff with impact on
staffing resource and challenge to maintain programmes of activity;
Implication of unknown long term drug abuse;
Organic dementia in younger population -changes in practice;
Changes in diagnostic pattern for admission e.g. personality
disorders, challenging behaviour, ASD, brain injury, ARBD;
Ageing population – more elderly patients;
Demographic changes;
Integrated Care Pathways (ICP);
HEAT targets – readmission rates, suicide prevention etc;
Positive risk taking;
Other services and community based agencies developing;
Bed availability and bed blocking due to the lack of alternative
community provision;
Future service demand is uncertain. This new provision needs to
reflect change in trends and be adaptable to future need;
All services being on one site will increase expectation of
rehabilitation unit helping out other areas at times of increased
demand with knock-on effect on programme within ward;
All adult inpatient beds are now housed on one site, therefore
contingency plans need to be considered in case of emergencies;
226
Appendix Q - Elderly Mental Health Wards
Introduction and outline of services
Departmental Function
The current purpose of the elderly mental health service is to offer an
integrated, comprehensive and flexible service for people aged 65 and over
with functional mental health problems; for all adults with a diagnosis of
dementia and their respective carers.
The service is provided through a combination of community, day care and
inpatient services working across Ayrshire and Arran. There is a significant
degree of partnership working with Local Authority community care older
people’s services both operationally and in the strategic planning of
services, which will be further developed based on identified best practice.
This template is in two sections, the elderly functional admission ward and
elderly organic admission ward.
Scope of Service/Specialist Services Provided
The accommodation is scheduled in Mental Health Services and is
described in the section entitled MH 15 Bed Wards - Elderly in the Schedule
of Accommodation.
The total bed complement for Elderly Mental Health Services will be 30,
initially divided into two 15 bed wards. The Elderly Mental Health unit should
be designed with enough flexibility to allow a change from 2 x 15 bed wards
to another configuration i.e. 1x 12 bed and 1 x 18 bed to meet changing
demands.
227
Model of Care – Elderly Functional Admission Ward
Descriptive Overview
The elderly functional admission ward will be suitable for the delivery and
receiving of therapeutic psychiatric care. The environment should be
conducive to providing care in a safe, homely type setting. The design
should be in accordance with the NHS Design Audit Tool.
Role and Function
The ward will provide assessment and treatment for older people with
mental health problems. The assessment will be part of a multi disciplinary
team approach and a formulation of a plan of care based on this
assessment will be implemented for each patient and a comprehensive
discharge plan agreed.
Usual admissions to this area will represent clients who:
•
•
•
•
•
Are deemed to be in crisis and have an identifiable psychiatric illness;
Require high levels of nursing observation;
Are at risk of harm to self or others;
Are at risk of severe self neglect; and
Require to be in hospital under terms of the Mental Health Act.
The ward function will ensure that the following principles are met:
Care will be patient centred;
Services must respect the individual;
Services must offer privacy and dignity;
Services must balance the need for safety and security with the provision of
a therapeutic environment;
The environment requires to lend itself to obtrusive and unobtrusive
observation; and
The environment must be pleasant, safe and the general ambience
promotes mental health well being.
Bed complement
228
15 beds provided in single room accommodation with en-suite facilities
The Elderly Mental Health unit should be designed with enough flexibility to
allow a change from 2 x 15 bed wards to another configuration i.e. 1x 12
bed and 1 x 18 bed to meet changing demands.
Bed provision will be in accordance with mixed sex guidance
Planned patient activity
Admissions will be accepted from a variety of sources such as:
Community Mental Health Teams
General Practitioners
Other hospitals
Care Homes
The average length of stay will be four to six weeks.
General principles of operation
All clinical, therapeutic and social care will be provided at the least restrictive
level appropriate to the needs of the client group;
Clinical interventions will be evidence based and reflect current best
practice; and
Invasive clinical interventions such as restraint, rapid tranquilisation,
venepuncture and assistance with personal hygiene tasks will be
undertaken in a safe, non stimulating environment that respects the
individual’s privacy and dignity, preferably in a patients own bedroom (one of
the 2 larger ones).
Design Synopsis
In addition to the core design synopsis/critical features, unique features to
this environment will be;
•
•
•
•
•
Doors, locks and windows should be of a design which is antibarricade and enables access by staff in an emergency;
Maximum use of natural and artificial light – daylight should be used
whenever possible as it delivers good colour rendition;
Maximum use of natural and artificial ventilation;
Discreet hotel and storage services;
Dining facilities that enhance the meal experience;
229
•
•
Clinical areas that are non threatening and welcoming; and
Common sitting and activity areas should be homely and domestic
while lending themselves to recovery.
230
Bedroom areas should enhance the therapeutic experience and also
provide privacy
There will need to be flexibility in approximately 10% of beds without
compromising mixed sex guidelines;
Adequate signage should be provided within ward areas;
All areas within the ward should be easily observable with no blind spots;
There should be one single point of entry to the ward;
Should be a ligature free environment; and
Outside designated smoking area should be well ventilated thereby
preventing smoke pollution of adjacent areas (currently a review of smoke
free premises).
Corridors: Required features
Corridor design is an important feature within the ward and should not just
be seen as a means of getting from A to B;
Corridors should provide seated areas for quiet contemplation;
Corridors should have no blind spots and allow maximum observation; and
Handrails should be fitted in accordance with Dementia Services
Development Design Guidelines.
231
Mixed gender requirements
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
•
•
The design of the facility must comply with current legislation
The building should be sensitive to the needs of physical and sensory
disabled patients, staff and visitors.
Privacy and dignity requirements
•
The design of the unit must comply with current legislation
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
The wards should have a shared reception/interview area
The elderly admission wards should be adjacent to each other and
connected by a common corridor; and
The wards should each have access to their own enclosed, safe, stimulating
and raised garden areas. The garden area should be secure and be
enclosed by a timber fence which will be bordered by shrubs.
232
The wards should have ease of access to the store rooms, cleaners’
(housekeeping) room, WC, patients laundry room, interview room and
social/activity/therapy area and be in close proximity to them;
The wards should have easy access to Support Cluster 3 without having to
go outside; and
The wards should have access to spiritual care area.
Internal
The open plan dining area and pantry should be close to the entrance of the
ward and distant to the bedrooms
Clean and dirty utility rooms and linen room should be away from the main
clinical areas;
Reception/Interview rooms should be distant from the bedrooms;
The bedrooms should be distant from the clean and dirty utility rooms, linen
room, interview room and open plan dining area;
The charge nurses office should be close to the office for 2 people but not at
the main entrance of the ward; and
The treatment room, bath, WC and wash : assisted, sitting room, office for 2
staff, disabled WC’s and pantry should be sited in such a way that allows
ease of access and use but distant from the dining room.
233
Storage facilities
The following storage facilities are required for:
Are required for
•
•
•
•
•
•
•
•
•
•
•
Clinical equipment such as moving and handling equipment
Flat linen and towels
Incontinence equipment
Miscellaneous items
Mobility aids
Patient personal possessions that are not stored in their own room
Range of seasonal equipment (eg Christmas decorations)
Spare duvets, pillows and mattresses
Therapeutic equipment
Wheelchairs
Hoists (portable ones)
Anticipated developments
The building should be able to meet the needs of future Information
technology developments
The building should be flexible in design to meet the challenges of an ever
changing and improving Health Service.
Client Group Characteristics
Age and Gender
65 years and over, male and female
234
Admission Rates
Admissions are accepted 365 days per year, 24 hours per day
Diagnoses
Clients admitted to the ward suffer from an identifiable mental disorder
Anticipated illness-related behaviours
Aggressive behaviour (verbal and physical);
Aimless or ritualistic behaviours;
Clients who are admitted to this ward may display the following;
Disinhibited behaviours;
Lack of personal risk awareness;
Suicide risk; and
Unpredictable and impulsive behaviours.
Anticipated clinical risks
Clients who are admitted to this ward may be at risk from the following:
Deliberate self harm;
Harm to others;
Poor mobility;
Poor motivation;
Self neglect; and
Suicidal intention.
Patient dependency characteristics
Poor physical health and associated mobility problems
Therapeutic Intent
235
Principal aims of clinical care
In-patient care is one element of the care pathway. It offers time limited
safety, support, therapy and treatment to people who are too unwell to be
cared for in a non hospital setting.;
Is not to be respite from other elements of the care pathway;
Is to improve the person’s mental and physical health and functioning; and
Is to provide a stepping stone to inclusion, not a departure point for
exclusion.
Therapies
Individual and group therapies will be provided within the facility on a
planned and ad-hoc basis; and
Therapies will enhance the care experience and will be focussed upon
specific interventions and outcomes.
Therapeutic facilities required
Adequate space to provide therapeutic interventions as required within the
ward;
Adequate space for physical activities; and
Adequate storage space to contain therapeutic equipment will be required
within the ward.
Planned clinical meetings
Adequate space is required for approximately 12 people to provide for a
variety of clinical meetings which will take place on a daily basis;
Case Conferences;
Consultant Meeting;
CPA Meetings;
Junior Doctor Reviews;
Multi-disciplinary meetings;
Nursing handover reports; and
One to one clinical interventions.
236
Other Meetings
Appraisal/supervision meetings;
Meetings with extended care team;
Meetings with relatives; and
Training and development and educational events for staff and relatives.
Clinical risk management principles
Based on this an initial risk management plan is developed;
On admission each patient is assessed in accordance with the recognised
risk assessment tool;
One element of this plan is to determine the person’s observation status;
and
Risk management for this client group is important. The environment must
be conducive to delivering the risk management plan.
Operational Procedures
Working day plans
The wards will be open 365 days per year and 24 hours per day
Staffing arrangements and shift patterns
Nursing handovers will take place a minimum of three times per day, mainly
morning, afternoon and evening.
The wards will be staffed 365 days per year and 24 hours per day
Admission procedures
Admissions are accepted at anytime. Some are arranged on a planned
basis, others are emergency
237
Record-keeping storage
All clinical case records require to be stored within a lockable cabinet within
a lockable room, office – electronic record keeping has been implemented
and records are stored as per record keeping guidelines in the admission
wards .
Items of secure stationery require to be stored within a lockable cabinet
Visiting arrangements
Facilities should be made available for visits of personal pets;
If the patients condition allows, visitors can take them to the café area in the
main entrance;
Visiting arrangements will be as agreed with ward team and may take place
within the visitors room or out with the ward area; and
A small sitting room will be available within the ward.
Mealtimes/dining arrangements
Dining will be ward based and there will be three mealtimes per day; and
Facilities must promote the ambiance of the meal experience.
Between meal snacks and access to beverages
Facilities should be available within the pantry area to permit the making of
hot and cold drinks and snacks out with recognised mealtimes
Laundry facilities and linen management
washing, drying, ironing and labelling of personal clothing will be carried out
in the central laundry on site
238
Model of Care – Elderly Organic Admission Ward
Descriptive Overview
The elderly organic admission ward will be suitable for the delivery and
receiving of therapeutic psychiatric care. The environment should be
conducive to providing care in a safe, homely type setting. The design
should be dementia friendly and in accordance with the Dementia Services
Development Centre, NHS Design Audit Tool.
The fundamental design principle is that of being able to find your way easily
from room to room in the course of normal daily activities.
Role and Function
The ward will provide assessment and treatment for older people with
mental health problems. The assessment will be part of a multi disciplinary
team approach and a formulation of a plan of care based on this
assessment will be implemented for each patient and a comprehensive
discharge plan agreed.
Usual admissions to this area will represent clients who:
•
•
•
•
•
Are deemed to be in crisis and have an identifiable psychiatric illness;
Require high levels of nursing observation;
Are at risk of harm to self or others;
Are at risk of severe self neglect; and
Require to be in hospital under terms of the Mental Health Act.
The ward function will ensure that the following principles are met:
•
•
•
•
•
•
Care will be patient centred;
Services must respect the individual;
Services must offer privacy and dignity;
Services must balance the need for safety and security with the
provision of a therapeutic environment;
The environment requires to lend itself to obtrusive and unobtrusive
observation; and
The environment must be pleasant, safe and the general ambience
promotes mental health well being.
239
Bed complement
15 beds provided in single room accommodation with en-suite facilities
The Elderly Mental Health unit should be designed with enough flexibility to
allow a change from 2 x 15 bed wards to another configuration i.e. 1x 12
bed and 1 x 18 bed to meet changing demands.
Bed provision will be in accordance with mixed sex guidance
Planned patient activity
Admissions will be accepted from a variety of sources such
Community Mental Health Teams;
General Practitioners;
Other hospitals; and
Care Homes.
General principles of operation
•
•
•
All clinical, therapeutic and social care will be provided at the least
restrictive level appropriate to the needs of the client group;
Clinical interventions will be evidence based and reflect current best
practice; and
Invasive clinical interventions such as restraint, rapid tranquilisation,
venepuncture and assistance with personal hygiene tasks will be
undertaken in a safe, non stimulating environment that respects the
individual’s privacy and dignity, preferably in a patients own bedroom
(one of the 2 larger ones).
Design Synopsis
In addition to the core design synopsis/critical features, unique features to
this environment will be;
•
•
All areas within the ward should be easily observable with no blind
spots
Bedroom areas should enhance the therapeutic experience and also
provide privacy
Bedrooms
240
•
•
•
•
Toilet visible from bed-head position;
Bed accessible from both sides;
Space for monitoring equipment; and
Dado rail to assist mobility.
•
•
•
Clinical areas that are non threatening and welcoming;
Common sitting and activity areas should be homely and domestic
while lending themselves to recovery and should not be open plan.
All sitting areas and activity areas should have natural daylight and a
pleasant outlook;
Outside designated smoking area should be well ventilated thereby
preventing smoke pollution of adjacent areas;
Dining facilities that enhance the meal experience;
Discreet hotel and storage services;
Doors, locks and windows should be of a design which is antibarricade and enables access by staff in an emergency; and
Appropriates colours and signage should be used.
•
Ligature points should be eliminated;
•
•
•
•
241
•
•
•
•
•
Maximum use of natural and artificial light;
Maximum use of natural and artificial ventilation;
The provision of hot/cold drinks should be available in the common
sitting/activity areas;
There should be no stepped areas within the ward; and
There should be one single point of entry to the ward.
Corridors: Required features
•
•
•
•
Corridor design is an important feature within the ward and should not
just be seen as a means of getting from A to B. Dementia Services
Development Design Guidelines (DSDC) guidelines should be
considered;
Corridors should have no blind spots and allow maximum
observation;
Corridors should provide seated areas for quiet contemplation; and
Handrails to be provided in corridors of elderly mental health services.
Mixed gender requirements
•
The design of the unit must comply with current mixed sex guidance
legislation
Disabled access requirements
•
•
The design of the facility must comply with current legislation
The building should be sensitive to the needs of physical and sensory
disabled patients, staff and visitors.
Privacy and dignity requirements
•
The design of the unit must comply with current legislation
242
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
•
•
•
•
•
The elderly admission wards should be adjacent to each other and
connected by a common corridor;
The wards should have access to enclosed, safe, stimulating and
raised garden areas; the garden should be designed using Dementia
Services Development Centre’s design principles. The garden should
be secured by the use of a timber fence which will be bordered by
shrubs.
The wards should have ease of access to store rooms, cleaners’
(housekeeping) room, WC, patients laundry room, interview room and
social/activity/therapy room and be in close proximity to them;
The wards should have easy access to Support Cluster 3 without
having to go outside; and
The wards should have access to the spiritual care area.
Internal
•
•
•
•
•
•
Clean and dirty utility room and linen room should be away from the
main clinical areas;
Reception/Interview room should be distant from the bedrooms;
The bedrooms should be distant from the clean and dirty utility room,
linen room, interview room [check name], charge nurse office and
open dining area;
The charge nurse office should be at the main ward entrance;
The open dining area and servery should be close to the entrance of
the ward and distant to the bedrooms; and
The treatment room, bath, WC and wash (assisted),
social/activity/therapy area, sitting room, office for 2 staff, WC dual
access and hand-wash, accessible, wheelchair assisted and pantry
should be sited in such a way that allows ease of access and use.
243
Storage facilities
The following storage facilities are required for:
•
•
•
•
•
•
•
•
•
•
Clinical equipment such as moving and handling equipment;
Flat linen and towels;
Incontinence garments;
Miscellaneous items;
Mobility aids;
Patient personal possessions that are not stored in their own room;
Range of seasonal equipment (eg Christmas decorations);
Spare duvets, pillows and mattresses;
Therapeutic equipment; and
Wheelchairs.
Anticipated developments
The building should be able to meet the needs of future Information
Technology developments; and
The building should be flexible in design to meet the challenges of an ever
changing and improving Health Service.
Client Group Characteristics
Age and Gender
Generally 65 years and over, however the ward will accommodate younger
people with dementia at times.
male and female
Admission Rates
Admissions are accepted 365 days per year, 24 hours per day.
Diagnoses
Clients admitted to the ward suffer from an identifiable organic mental
disorder
244
Anticipated illness-related behaviours
Clients who are admitted to this ward may display the following;
•
•
•
•
•
•
•
Aggressive behaviour (verbal and physical);
Aimless or ritualistic behaviours;
Disinhibited behaviours;
Lack of personal risk awareness;
Resistiveness to care interventions;
Unpredictable and impulsive behaviours; and
Wandering behaviour.
Anticipated clinical risks
•
•
•
•
•
•
•
Clients who are admitted to this ward may be at risk from the
following:
Falls;
Harm to others;
Poor mobility;
Poor motivation;
Poor nutrition; and
Self neglect.
Patient dependency characteristics
•
•
•
•
•
•
Incontinence;
Other neuropsychiatric symptoms;
Poor mobility problems;
Poor physical health;
Significant cognitive impairment; and
Tissue viability problems.
Therapeutic Intent
Principal aims of clinical care
•
•
•
•
Assessment of a person’s future care and needs and how they can
be safely met;
In-patient care is one element of the care pathway. It offers time
limited safety, support, therapy and treatment to people who are too
unwell to be cared for in a non hospital setting;
Is not to be respite from other elements of the care pathway; and
Is to improve the person’s mental and physical health and
245
functioning.
Therapies
Individual and group therapies will be provided within the facility on a
planned or ad-hoc basis; and
Therapies will enhance the care experience and will be focussed upon
specific interventions and outcomes.
Therapeutic facilities required
Adequate space to provide therapeutic interventions as required within the
ward; and
Adequate storage space to contain therapeutic equipment will be required
within the ward.
Planned clinical meetings
•
•
•
•
•
•
•
•
Adequate space is required to provide for a variety of clinical
meetings which will take place on a daily basis;
Case Conferences;
Consultant Meeting;
CPA Meetings;
Junior Doctor Reviews;
Multi-disciplinary meetings;
Nursing handover reports; and
One to one clinical interventions.
Other Meetings
•
•
•
•
Appraisal/supervision meetings;
Meetings with extended care team;
Meetings with relatives; and
Training, development and educational venues.
Clinical risk management principles
•
•
Based on this an initial risk management plan is developed;
On admission each patient is assessed in accordance with the
246
•
•
recognised risk assessment tool;
One element of this plan is to determine the person’s observation
status; and
Risk management for this client group is important. The environment
must be conducive to delivering the risk management plan.
Operational Procedures
Working day plans
The wards will be open 365 days per year and 24 hours per day
Staffing arrangements and shift patterns
Nursing handovers will take place a minimum of three times per day, mainly
morning, afternoon and evening; and
The wards will be staffed 365 days per year and 24 hours per day.
Admission procedures
•
Admissions are accepted at anytime. Some are arranged on a
planned basis, others are emergency.
Record-keeping storage
All clinical case records require to be stored within a lockable cabinet within
a lockable room. E-records are implemented within admission wards and
are stored under record keeping guidelines; and
Items of secure stationery require to be stored within a lockable cabinet.
Visiting arrangements
Access facility for the visiting of personal pets;
If the patients condition allows, visitors can take them to the café area in the
main entrance; and
Visiting arrangements will be as agreed with ward team and may take place
within the visitors room or outwith the ward area.
Mealtimes/dining arrangements
247
Dining areas will require to be of varying sizes to accommodate people with
severe dementia and/or with wandering behaviour ;
Dining will be ward based and there will be three mealtimes per day; and
Facilities must promote the ambiance of the meal experience.
Between meal snacks and access to beverages
Facilities should be provided within the pantry area to allow for the making of
hot and cold drinks and snacks out with the recognised mealtimes.
Laundry facilities and linen management
A room is required to provide for the washing, drying, ironing and labelling of
personal clothing.
Functional content
Number of Inpatient Beds/Treatment Spaces
30 beds, 15 functional and 15 organic beds
Investigative/Diagnostic/Treatment Capacity:
Access to labs and imaging will be required
Outpatient Service (Number of Sessions and
specialist functions):
•
Not applicable
Specialist Technical Infrastructure Requirements
2222 (emergency response)
ECT
Gas cylinder storage
Intercom
248
IT systems
O2
Personal alarm systems
Radio comms, pagers
Satellite communications
Security entry – slow doors
Suction
Telemedicine/teleconferencing (tele-education)
Projected Future Activity
Increase in number of older people which will impact on the potential
number of people with dementia and other mental illness. Increased
demands on community mental health teams in respect of assessment,
interventions and delivery of appropriate support packages both for person
with dementia and other mental illness, their families and carers.
The projected increase in the elderly population will invariably impact on the
demand for inpatient beds.
The key projected demographic change that will impact on mental health
services in the medium term will be a significant increase in the proportion of
older people within Ayrshire and Arran.( General Register Office for
Scotland, 2007, Projected Population of Scotland (2006 based)
Currently 18.2% of the Ayrshire and Arran population is aged over 65 years
(up from 17% in 2004). There is a projected rise in the 65-74 population in
Ayrshire between 2006 and 2021, of 14%, from 36,851 to 42,124. Between
the Local Authority areas, North Ayrshire is projected to increase by 16%,
East Ayrshire by 11% and South Ayrshire by 13%. (The Social Work
Services Inspectorate for Scotland, 1996: Population Needs Assessment in
Community Care. Handbook for Planners and Practitioners)
More significantly, the over 75 population is projected to rise by 44%, from
29,995 to 43,192. The increase in the over 75 population is projected to
vary between Local Authority areas with rises of 41% in East Ayrshire, 50%
2
in North Ayrshire and 41% in South Ayrshire.
The rates of dementia are also likely to rise commensurately: an estimated
5% of those aged 60-80 and 20% of those aged 80+ will have a form of
249
dementia
The overall age distribution of the Ayrshire population is as shown in Table 1
below:
Table 1
(General Register Office for Scotland mid-year estimates, 2007.)
Area
Under 15
years
15-64 years
65+
Total
Ayrshire
60,483
239,591
66,946
367,020
16.5%
65.3%
18.2%
100%
23,144
88,639
23,977
135,760
17%
65.3%
17.7%
37%
20,060
79,317
20,193
119,570
16.8%
66.3%
16.9%
32.6%
17,279
71,635
22,776
111,690
15.5%
64.1%
20.4%
30.4%
North
East
South
250
Key Relationships with Other Departments/NHS
Ayrshire and Arran /Social Services/Social
Work/Local Authority Services
Close to
Adult mental health
Reason
Professional
development
Category*
Essential
Ease of transition
Geriatric medicine
Ease of transition
Essential
Local Authority social
work staff
Facilitate timely
discharge and establish
appropriate care
packages
Essential
Primary care colleagues
Establishment of
seamless care
Essential
Other healthcare
professionals
Maintenance of
effectiveness of multidisciplinary working
Essential
Universities (Glasgow
and West of Scotland)
Continuing development
Essential
Voluntary sector
Collaborative working
Essential
Leisure and recreational
facilities
Improved physical health
and mental wellbeing
Important
Patient focus public
involvement
Engaging service users
and carers to ensure
establishment of
appropriate quality
services
Essential
Closer links with local
community
to minimise stigma
Desirable
Support Cluster 3
•
•
•
•
Ease of access for Desirable
inpatients
Safety
Staff assistance
Accessible
for
visiting agencies
* Category: Essential/Important/Desirable
251
Future Service Delivery Risks
Failure to secure appropriate decant facilities if required for the current
Pavilion 1 and Pavilion 2 patients.
Observation of disturbed patients
Unable to attract appropriately qualified staff, including medical and nursing
staff.
Financial resources
Current service risks
Isolated from rest of elderly mental health inpatient areas
Lack of appropriate daily living space
Lack of single rooms
Professional isolation due to standalone nature of elderly mental health unit
Accommodation – not fit for purpose
Patient mix – gender
Limited private space for visitors and family members
Poor access for disabled and hotel services and staff/patients, no
pavements
Long walk from bus stop to ward areas and clinic
Isolated out of hours and staff backup
Observation of disturbed patients
Unable to predict demand for inpatient beds
Male/female mix segregation
252
Appendix R - Rehabilitation Ward (General
Health)
Introduction and outline of services
Departmental Function
The care of the elderly directorate provides a range of inpatient, outpatient
and day hospital Rehabilitation services on the Ayrshire Central site.
•
Scope of Service/Specialist Services Provided
The accommodation is scheduled in the Community Hospital and is
described in the section entitled Rehabilitation ward in the Schedule of
Accommodation.
Model of Care
Descriptive Overview
The principal policy goal of the Reshaping Care for Older People
Programme is to “optimize independence and wellbeing for older people at
home or in a homely setting”. The vision for the future delivery of Services
for Older People on the new Ayrshire Central site reflects this overarching
goal and is based on an integrated pathway approach that encourages
multi-disciplinary and multi-agency working model across health and social
care and which allows the patient a seamless journey between primary care,
secondary care and the community.
This vision reflects NHS Ayrshire and Arran’s commitment to Reshaping
Care for Older People and is an integral part of North Ayrshire CHP’s local
Reshaping Care for Older People strategy. The North Ayrshire Joint
Commissioning Strategy 2009-12 has been developed with input from key
stakeholders, including older people and carers, to support the following key
priority areas:
Delivering a Joint Commissioning Strategy for older people
Establishing an integrated model of rehabilitation and enablement services
that includes Local Authority, Health, Voluntary and Independent sectors.
253
Reducing emergency admissions amongst people over 75 years
Reducing delayed discharges from a maximum of 6 weeks to 4 weeks
Shifting the balance from hospital based to community based intensive
support services for older people. This will include development of Housing
options that support independence for people with long term health
conditions.
Developing services which sustain independence and promote self
management amongst older people reducing Care Home placements
Developing informal social networks which promote the health and wellbeing
of older people
Reducing hospital bed days experienced by older people due to delayed
discharges and emergency admissions
Implementing the national Dementia Strategy
Implementing the Housing Options Strategy for Older People
In order that patients can be cared for in the most appropriate setting for
their needs a range of in-patient, out-patient, day hospital and community
services for older people will be provided. Access to the Ayrshire Central
Hospital will be through a multidisciplinary Team who will be responsible for
the patients care whilst in Ayrshire Central and also responsible for ensuring
a smooth and supported discharge to allow patients to return to the
community at the earliest opportunity.
A range of services for older people are currently being developed through
our Reshaping Care Programme supported by the Change Fund aimed at
preventing avoidable hospital admission and/or facilitating early discharge
by offering more care in the community and increased levels of community
rehabilitation. Work is ongoing to redesign the model of care currently
provided in our Day Hospitals and to develop a more community based
geriatric service. This will enable patients to be admitted to Ayrshire Central
directly from the community where appropriate thus avoiding the need to be
admitted to Crosshouse. This will ease the patient journey and reduce the
overall length of stay.
Our vision will be supported by the development of an integrated health and
social care model which will bring together a wide range of services. These
integrated hubs will have a Single Point of Contact and will potentially
include:
•
•
•
•
•
•
•
Intermediate Care and enablement services
Home from hospital services,
Public Health Services
Community Nurses
Social Work and home care staff
Allied Health Professionals
Community Ward staff
254
•
•
Community based Geriatrics service
Community based elderly mental health services
The integration and potential co-location of these staff will promote a multidisciplinary, multi-sectoral approach to services for older people, breadth of
skills and expertise across the team, promote flexibility and help the team to
develop a collective understanding of the needs of the local population and
maintain long-term sustainability of services.
The vision also recognizes that frail older patients deemed ready for
discharge are a dynamic groups whose care plan and support needs may
change and local pathways will ensure optimal opportunity for individuals
with complex need to exhibit late and often unexpected potential for a home
based discharge.
The new hospital facilities will enable a range of planned care services to be
developed locally ensuring the hospital is seen as a local community
resources centre providing a bridge between home and acute hospital care.
Although there will be an increasing emphasis on community based
rehabilitation a number of specialist wards and services will continue to
provide rehabilitation services for those who need them. It is anticipated that
changes in service delivery will mitigate against increased activity as a result
of demographic changes. This will comprise of:
30 assessment and rehabilitation beds for patients transferring from the
wards at Crosshouse
Outpatient services including a daily geriatric immediate access clinic (Mon
– Fri 1.00-3.30pm) which will help to prevent avoidable hospital admissions
as well as allow direct admission to the new community hospital where
appropriate.
12 day hospital places
In partnership with the three Local Authorities the Rapid Response Service
has been transformed over the last eighteen months from a hospital based
service into an integrated locality based intermediate Care and Enablement
Service. The skill mix within the team has been strengthened and the team
now comprises of staff from across the all the allied health professions,
community pharmacy, nursing and social care as well as input from
Consultant Geriatricians and advanced Rehabilitation Nurse Practitioners.
This Intermediate Care Team is also integral to the development of a new
Falls Pathway. This redesign work will allow more complex rehabilitation to
255
be undertaken in the community and will contribute to a reduction in
admissions and a reduction in length of stay for older people.
The Care of the Elderly vision also anticipates a physical adjacency with the
Elderly Mental Health wards would provide the potential for developing
flexible services and for sharing knowledge, training & experience. There is
also a potential for shared space between the two specialties.
The Care of the Elderly Directorate will work with the Diagnostics Directorate
to ensure that there are appropriate services on the Ayrshire Central site
and where this is not possible that services at Crosshouse are scheduled to
ensure that the patient pathway is streamlined to ensure that patient can
be transferred to Ayrshire Central without delay or unnecessary increases in
length of stay.
Role and Function
A range of in-patient, out-patient, day hospital and community services for
older people will be provided.
Although there will be an increasing emphasis on community based
rehabilitation a number of specialist wards and services will continue to
provide in-patient services for those who need them.
Bed complement
•
30 inpatient General Rehabilitation beds
256
General principles of operation
Design Synopsis
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Windows should be of a height that allows patients to see out of them
when seated
Maximise use of natural light;
Disability Discrimination Act compliant;
Occasional seating in corridors for patients to rest;
Seated areas for quiet contemplation;
Link with current dementia/visual impairment services to seek advice
on design and decoration;
Look at Palliative Care specific area/suit to include relative overnight
facilities. Should there be consideration of a couple of rooms being
two bedded to allow for management for partner admissions,
management of challenging behaviour, depression/social isolation;
At least one bathroom per ward to have overhead tracking hoists;
Maximum use of natural and artificial ventilation;
Discreet hotel and storage services;
Dining facilities that enhance the meal experience;
Clinical areas that are non threatening and welcoming;
Common sitting and activity areas should be homely and domestic
while lending themselves to recovery and should not be open plan;
Bedroom areas should enhance the therapeutic experience and also
provide privacy;
Adequate signage should be provided within ward areas;
All areas within the ward should be easily observable with no blind
spots;
There should be one single point of entry to the ward;
Should be a ligature free environment; and
Consideration should be given to the distance that carers would have
to walk taking into account their mobility, this should kept to a
minimum.
Corridors: Required features
•
•
•
•
•
•
Maximise use of natural light;
DDA compliant;
Hand Rails required;
occasional seating required for patients to rest;
Link with current dementia/visual impairment services to seek advice
on design and decoration; and
Wide capacity – to take 2 way traffic.
Mixed gender requirements
•
The design must comply with current guidance and legislation;
257
•
•
Double room for partner admissions; and
Alternative sitting areas – specifically television areas and sitting
areas.
Disabled access requirements
•
•
•
•
Must be DDA compliant, including loop system;
All rooms/en-suites must be large enough to accommodate the use of
patient hoists;
Specific one bedroom per ward to facilitate bariatric patients; and
Comfortable door width for ease of access/movement of beds.
Privacy and dignity requirements
•
•
•
All rooms to be en-suite;
Separate male/female toilets in shared areas; and
The design of the unit must comply with current legislation.
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
•
•
•
•
•
•
•
•
The rehabilitation ward should be located beside the long term care
ward and elderly mental health wards;
The ward should have access to enclosed, safe, stimulating and
raised gardens;
The ward should have ease of access to the store room, cleaners’
(housekeeping) room, patients laundry room, interview room, duty
room and multi-disciplinary room and be in close proximity to them;
The ward should have easy access to the main entrance without
having to go outside;
Patients should have access to the spiritual care area;
Ambulance/undertaker access bay;
Ease of access within the hospital grounds for patients and visitors;
and
Parking facilities adjacent to front door to allow ease of transferring
equipment into van for transporting to patients homes.
258
Internal
•
•
•
•
•
•
•
•
Dining rooms and servery should be close to the entrance of the ward
and distant to the bedrooms;
Clean and Dirty utility room and store room should be away from the
main clinical areas;
Interview room should be distant from the bedroom;
Second sitting room should be sited in accordance with the mixed sex
guidance;
The bedrooms should be distant from the clean and dirty utility
rooms, store room, interview room, charge nurse office and dining
rooms;
The charge nurses office should not be at the main ward entrance ;
The treatment room, bath, WC and wash assisted room, sitting
rooms, duty room, disabled WCs and pantry should be sited in such a
way that allows ease of access and use but distant from the dining
room; and
The wards should be close to:
o
Support cluster 3
o
Diagnostic dept.
o
Day hospital, provided in Douglas Grant Rehab Centre
o
Central walk-in entrance.
Storage facilities
The following storage facilities are required for:
•
•
•
•
•
•
•
Stores for bulky disposable items, eg. Hoists + slings + drip stands +
infusion devices;
Stores –large bulky items such as continence supplies/urinals,
bedpans;
The treatment room should contain a lockable storage cupboard
(0.8m x 0.5m for podiatry clinical instruments);
continence supplies/urinals, bedpans;
Spare duvets, pillows and mattresses;
Wheelchairs; and
RRS equipment – OT aids, Physiotherapy aids, nursing aids.
Anticipated developments
•
•
The building should be able to meet the needs of future Information
Technology developments
The building should be flexible in design to meet the challenges of an
ever changing and improving Health Service
259
Client Group Characteristics
Age and Gender
•
•
65 years of age and over
Male and female
Admission Rates
•
Admissions are accepted 365 days per year
Diagnoses
•
General geriatric medical conditions
Anticipated illness-related behaviours
•
•
•
•
•
•
Confusion;
Aimless behaviour;
Wandering;
Aggressive behaviour, both verbal and/or physical; and
Disinhibited Behaviour.
Anticipated clinical risks
•
•
•
•
•
•
Poor physical health and related physical dependency;
Poor mobility;
Risk of falling;
Poor motivation
Mild to moderate dementia
Depression
Patient dependency characteristics
Therapeutic Intent
For most patients in-patient care is part of the care pathway. It offers
assessment, treatment and rehabilitation and support to people who cannot
be cared for in a non-hospital setting.
260
Principal aims of clinical care
Therapies
•
•
Individual and group therapies will be provided on a planned and adhoc basis; and
Therapies will enhance the care experience and be focussed on
specific interventions and outcomes.
Therapeutic facilities required
•
Therapeutic facilities will be provided for in Support Cluster 3.
Planned clinical meetings
•
•
•
•
Weekly multidisciplinary meetings;
Ward Rounds;
Case conferences; and
Nursing handover reports.
Other Meetings
•
•
•
•
•
Ward staff meetings;
Meetings with discharge coordinator/social workers;
Appraisal/supervision meeting;
Meetings with relatives; and
Training and development.
Clinical risk management principles
•
Each patient will be assessed on admission using recognised risk
assessment tools and a risk management plan put in place.
261
Operational Procedures
Working day plans
•
•
24 hours a day/365 days per year
Day services
Staffing arrangements and shift patterns
•
•
Mix of long/short shifts (5 hr – 11.5 hr)
Admission procedures
•
Established admission protocols in place
Record-keeping storage
•
•
Lockable storage facility
IT infrastructure and full range of appropriate systems
Visiting arrangements
•
Limited but flexible in rehabilitation wards
Mealtimes/dining arrangements
•
Separate from sitting areas
Between meal snacks and access to beverages
•
Should be available throughout the day
Laundry facilities and linen management
•
On site
262
Adult Recreational Facility
•
•
•
•
TV areas, quiet areas, activity areas;
Hairdressing/barber facility;
Also large social gathering area for large functions for example,
concerts/bingo/bowls/teas; and
Patient computer/internet/e-mail access should be available as
increasing number of patients computer literate.
Functional content
Number of Inpatient Beds/Treatment Spaces
•
30 rehab inpatient beds
Investigative/Diagnostic/Treatment Capacity:
•
•
•
Access to x-ray, pharmacy and labs required with ECG Technician, xray and ultrasound on site;
CT, SPECT, MRI, Video fluoroscopy, Pulmonary Function &
Cardiology testing provided at Crosshouse Hospital; and
Electronic access to laboratory results.
Outpatient Service (Number of Sessions and
specialist functions):
•
Not applicable
Specialist Technical Infrastructure Requirements
•
•
•
•
•
2222 (emergency response);
Gas cylinder storage;
O2;
Suction; and
Hoist tracking systems.
Projected Future Activity
263
Key Relationships with Other Departments/NHS
Ayrshire and Arran /Social Services/Social
Work/Local Authority Services
Close to
Elderly Mental Health
•
•
Central (Walk-in)
Entrance
•
Ambulance Entrance
•
Reason
Category*
Essential
Shared
knowledge,
training
&
experience.
Potential
for
developing flexible
services
Desirable
Ease for patients
Multidisciplinary Team ++
•
Transfers from & Essential
attendance
at
General Hospitals
Access
for
Undertakers
Essential
MDT Working
MS Specialist Nurses
•
MDT Working
Essential
Wheelchair Service
•
MDT Working
Essential
Consultant in
Rehabilitation Medicine
•
MDT Working
Essential
Local Authorities
Partnership
Working
• Partnership
Working
• Shared
knowledge,
training
&
experience.
• Potential
for
developing flexible
services
• to allow ease of
transferring
equipment into van
for
transporting
patients homes
• Ease of access for
inpatients
• Safety
• Staff assistance
•
Voluntary Sector
Long Term Care Ward
Parking
Support Cluster 3
•
Important
Desirable
Essential
Desirable
Essential
264
•
•
•
Horizontal adjacency to
Elderly Continuing Care
ward
Accessible
for
visiting agencies
Access to shared
staff resources
* Category: Essential/Important/Desirable
++ Dietetics, Speech & Language Therapy, Physiotherapy, OT, Psychology,
Podiatry
Close to
Reason
Local Authority – NAC
To promote joint working
essential
and sharing of information
across both Health and
Social Services
Home care services
Category
Future Service Delivery Risks
•
•
•
•
•
•
•
Access to essential supporting services/facilities/people;
Fit with integrated care pathways;
Health & Safety (anti-ligature);
Prevention of falls, observation areas and high observation areas;
Recreation, diversion/rehab activities;
Throughput activity/case mix change; and
Patients with dementias/behavioural problems in same units as
general elderly patients and palliative care patients.
•
265
Appendix S – Long Term Care (continuing care)
Introduction and outline of services
Departmental Function
Patients over 65 years of age may be admitted to a continuing care ward
when the Hospital Consultant, in conjunction with the multi-disciplinary team
from the discharging area, has decided that the patient requires ongoing and
regular specialist clinical care or where the patient requires to undergo a
period of further assessment to determine how their long term care needs
can best be met.
Scope of Service/Specialist Services Provided
The accommodation is scheduled in the Community Hospital and is
described in the section entitled Long term care (continuing care) in the
Schedule of Accommodation.
Model of Care
Descriptive Overview
The vision for the future delivery of Care of the Elderly Services on the new
Ayrshire Central site is based on an integrated pathway approach that
encourages multi-disciplinary and multi-agency working model across health
and social care and which allows the patient a seamless journey between
primary care, secondary care and the community.
This vision is based on the view that patients should be cared for in the most
appropriate setting for their needs. A range of in-patient, out-patient, day
hospital and community services for older people will be therefore be
provided
The principal policy goal of the Reshaping Care for Older People
Programme is to “optimize independence and wellbeing for older people at
home or in a homely setting”.
Following a multi-disciplinary assessment the Hospital Consultant, in
266
conjunction with the multi-disciplinary team, may decide that the patient
requires ongoing and regular specialist clinical care on an in-patient basis
due to the complex nature or intensity of his or her health care needs. Our
vision, therefore, is to provide homely environment within our continuing
care wards that meets the mental, physical, emotional and spiritual needs of
this small group of patients who require ongoing hospital care.
Our long stay wards also act as a bridge between acute hospital care and
the community for those patients whose needs can best be met in their own
home.
In line with Reshaping Care for Older People it is our aspiration that older
people should not be admitted directly to a care home from an acute
hospital and we want our long-stay wards to provide an intermediate care
setting where patient’s community care assessments can be carried out.
Our long stay ward will also provide a homely, supportive environment for
patients requiring respite care and for palliative care patients whose needs
can best be met in a hospital setting
The vision also recognizes that frail older patients deemed ready for
discharge are a dynamic groups whose care plan and support needs may
change and local pathways will ensure optimal opportunity for individuals
with complex need to exhibit late and often unexpected potential for a home
based discharge.
A key goal in our Joint Reshaping Care for Older People Strategy is to
reduce the maximum time for patients undergoing Single Shared
Assessments from six weeks to four weeks and to reduce the number of
bed days lost to delayed discharges. We anticipate that changes in service
delivery will mitigate against increased activity as a result of demographic
changes. Consequently we will reduce our current complement of continuing
care beds from sixty to thirty prior to the opening of the new North Ayrshire
Community Hospital which s will comprise of:
30 continuing care beds for those patients requiring NHS continuing care or
who are undergoing assessment prior to discharge home or to a nursing
home ( a 30 bed reduction)
The Care of the Elderly vision also anticipates a horizontal adjacency with
the Elderly Mental Health wards would provide the potential for developing
flexible services and for sharing knowledge, training & experience. There is
also a potential for shared space between the two specialties.
267
Role and Function
A range of in-patient, out-patient, day hospital and community services for
older people will be therefore be provided
Although there will be an increasing emphasis on community based
rehabilitation a number of specialist wards and services will continue to
provide in-patient services for those who need them
Bed complement
30 long term (continuing care) beds
Planned patient activity
General principles of operation
Design Synopsis
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
The ward requires to be on the ground floor
Windows should be of a height that allows patients to see out of them
when seated
Maximise use of natural light;
Disability Discrimination Act compliant;
Occasional seating in corridors for patients to rest;
Seated areas for quiet contemplation;
Link with current dementia/visual impairment services to seek advice
on design and decoration;
Relatives overnight accommodation to allow family members to stay
when required, should be situated near to Elderly Services wards.
At least one bathroom per ward to have overhead tracking hoists;
Maximum use of natural and artificial ventilation;
Discreet hotel and storage services;
Dining facilities that enhance the meal experience;
Clinical areas that are non threatening and welcoming;
Common sitting and activity areas should be homely and domestic
while lending themselves to recovery and should not be open plan;
Bedroom areas should enhance the therapeutic experience and also
provide privacy;
268
•
•
•
•
Adequate signage should be provided within ward areas;
All areas within the ward should be easily observable with no blind
spots;
There should be one single point of entry to the ward; and
Should be a ligature free environment.
Corridors: Required features
•
•
•
•
•
•
Maximise use of natural light;
DDA compliant;
Hand Rails required;
occasional seating required for patients to rest;
Link with current dementia/visual impairment services to seek advice
on design and decoration; and
Wide capacity – to take 2 way traffic.
Mixed gender requirements
The design must comply with current guidance and legislation;
Alternative sitting areas – specifically television areas and sitting areas.
Disabled access requirements
Must be DDA compliant, including loop system;
All rooms/en-suites must be large enough to accommodate the use of
patient hoists;
Specific one bedroom per ward to facilitate bariatric patients; and
Comfortable door width for ease of access/movement of beds.
Privacy and dignity requirements
All rooms to be en-suite;
Separate male/female toilets in shared areas; and
The design of the unit must comply with current legislation.
269
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
•
•
•
•
•
•
•
•
The continuing care ward should be located beside the rehabilitation
ward and elderly mental health wards to allow sharing of facilities and
to encourage integrated working;
The ward should have access to enclosed, safe, stimulating and
raised gardens with adequate wandering and walking spaces;
The ward should have ease of access to the store room, cleaners’
(housekeeping) room, patients laundry room, interview room, duty
room and multi-disciplinary room and be in close proximity to them;
The ward should have easy access to the main entrance without
having to go outside;
Patients should have access to the spiritual care area;
Ambulance/undertaker access bay;
Ease of access within the hospital grounds for patients and visitors;
The rehabilitation ward should be adjacent to the Elderly Mental
Health wards to allow sharing of facilities and to encourage integrated
working;
Internal
•
•
•
•
•
•
•
•
•
Dining rooms and servery should be close to the entrance of the ward
and distant to the bedrooms;
Clean and Dirty utility room and store room should be away from the
main clinical areas;
Interview room should be distant from the bedroom;
Second sitting room should be sited in accordance with the mixed sex
guidance;
The bedrooms should be distant from the clean and dirty utility
rooms, store room, interview room, charge nurse office and dining
rooms;
The charge nurses office should not be at the main ward entrance;
The treatment room, bath, WC and wash assisted room, sitting
rooms, duty room, disabled WCs and pantry should be sited in such a
way that allows ease of access and use but distant from the dining
room; and
The wards should be close to:
Support cluster 3
270
•
Central walk-in entrance.
Storage facilities
The following storage facilities are required for:
•
•
•
Stores for bulky disposable items, eg. Hoists + slings + drip stands +
infusion devices
Stores –large bulky items such as continence supplies/urinals,
bedpans continence supplies/urinals, bedpans, spare duvets, pillows
and mattresses
Wheelchairs
Anticipated developments
The building should be able to meet the needs of future Information
Technology developments; and
The building should be flexible in design to meet the challenges of an ever
changing and improving Health Service.
Client Group Characteristics
Age and Gender
65 and over
Male and female
Admission Rates
•
Admissions are accepted 365 days per year
Diagnoses
•
•
Wide range of general medical conditions
Mild to moderate dementia
271
Anticipated illness-related behaviours
Confusion;
Aimless behaviour;
Wandering;
Aggressive behaviour, both verbal and/or physical; and
Disinhibited Behaviour.
Anticipated clinical risks
Poor physical health and related physical dependency;
Poor mobility;
Risk of falling;
Poor motivation
Mild to moderate dementia
Depression
Patient dependency characteristics
Therapeutic Intent
For most patients in-patient care is part of the care pathway. It offers
assessment and treatment and support to people who cannot be cared for in
a non-hospital setting; and
For some patients requiring long-term continuing care the ward is their
permanent home.
Principal aims of clinical care
Therapies
Individual and group therapies will be provided on a planned and ad-hoc
basis; and
Therapies will enhance the care experience and be focussed on specific
interventions and outcomes.
272
Therapeutic facilities required
•
Therapeutic facilities will be provided for in Support Cluster 3.
Planned clinical meetings
Weekly multidisciplinary meetings;
Ward Rounds;
Case conferences; and
Nursing handover reports.
Other Meetings
Ward staff meetings;
Meetings with discharge coordinator/social workers;
Appraisal/supervision meeting;
Meetings with relatives; and
Training and development.
Clinical risk management principles
Each patient will be assessed on admission using recognised risk
assessment tools and a risk management plan put in place.
273
Operational Procedures
Working day plans
•
24 hours a day/365 days per year
Staffing arrangements and shift patterns
Mix of long/short shifts (5hr – 11.5hr)
Admission procedures
Established admission protocols in place
Record-keeping storage
Lockable storage facility
IT infrastructure and full range of appropriate systems
Visiting arrangements
Open visiting to continuing care
Mealtimes/dining arrangements
Separate from sitting areas
Between meal snacks and access to beverages
Should be available throughout the day
Laundry facilities and linen management
On site
274
Adult Recreational Facility
•
•
•
•
TV areas, quiet areas, activity areas,
Hairdressing/barber facility.
Also large social gathering area for large functions eg
concerts/bingo/bowls/teas
Patient computer/internet/e-mail access should be available as
increasing number of patients computer literate
Functional content
Number of Inpatient Beds/Treatment Spaces
•
30 long term care (continuing care) inpatient beds
Investigative/Diagnostic/Treatment Capacity:
•
•
•
Access to x-ray, pharmacy and labs required with ECG Technician, xray and ultrasound on site;
CT, SPECT, MRI, Video fluoroscopy, Pulmonary Function &
Cardiology testing provided at Crosshouse Hospital; and
Electronic access to laboratory results.
Outpatient Service (Number of Sessions and
specialist functions):
•
Not applicable
Specialist Technical Infrastructure Requirements
•
•
•
•
•
2222(emergency response);
Gas cylinder storage;
O2 - piped to at least 4 beds per area;
Suction; and
Hoist tracking systems.
275
Key Relationships with Other Departments/NHS
Ayrshire and Arran /Social Services/Social
Work/Local Authority Services
Close to
Elderly Mental Health
•
•
Central (Walk-in)
Entrance
•
Ambulance Entrance
•
•
Reason
Category*
Essential
Shared
knowledge,
training
&
experience.
Potential
for
developing flexible
services
Desirable
Ease for patients
Transfers from & Essential
attendance
at
General Hospitals
Access
for
Undertakers
•
Local Authorities
•
Voluntary Sector
•
Support Cluster 3
•
•
•
•
•
Important
Partnership
Working
Desirable
Partnership
Working
Ease of access for Essential
inpatients
Safety
Staff assistance
Accessible
for
visiting agencies
Access to shared
staff resources
Horizontal adjacency
close to Elderly Rehab
ward
* Category: Essential/Important/Desirable
++ Dietetics, Speech & Language Therapy, Podiatry
Close to
Reason
Category
Local Authority – NAC
To promote joint working
essential
and sharing of information
276
Home care services
across both Health and
Social Services
Future Service Delivery Risks
•
•
•
•
•
•
•
Access to essential supporting services/facilities/people;
Fit with integrated care pathways;
Health & Safety (anti-ligature);
Prevention of falls, observation areas and high observation areas;
Recreation, diversion/rehab activities;
Throughput activity/case mix change; and
Patients with dementias/behavioural problems in same units as
general elderly patients and palliative care patients.
277
Appendix T - Support Clusters
Introduction and outline of services
Departmental Function
Within North Ayrshire Community Hospital there will be three support
clusters associated with 3 separate areas, namely:
Support Cluster 1
Support Cluster 1 will provide therapy space for Adult Acute Mental Health
inpatient Wards and occasionally the Intensive Psychiatric Care Unit. This
support cluster will be accessed by up to 68 beds.
The support cluster will allow patients to access mainly AHP led therapies in
a safe environment closely linked with their ward area.
Support Cluster 2
Support Cluster 2 will provide therapy space for Adult Mental Health
Rehabilitation Unit, addiction ward and the Forensic Rehabilitation/low
secure ward. The support cluster will be access by up to 48 beds.
Support Cluster 3
Support Cluster 3 will provide therapy space for Elderly mental health wards,
frail elderly continuing care ward and frail elderly rehabilitation ward. The
support cluster will be access by up to 90 beds.
Scope of Service/Specialist Services Provided
The accommodation is scheduled in the Mental Health section and is
described in the section entitled Support Cluster 1 (AMH), Support Cluster 2
(MH), Support Cluster 3 (Elderly) in the Schedule of Accommodation.
278
Model of Care
Descriptive Overview
The vision for the support cluster is to provide therapy, recovery and
exercise to patients using the facility. Each patient will have a designated
support cluster which will be adjacent to their ward area. We have
scheduled this area with three clusters, however a design would be
considered as long as the area scheduled is the same or more.
Role and Function
The role of the support cluster will be to provide therapy, recovery and
exercise to patients using the facility.
Bed complement
There will be no inpatient beds associated with any support clusters
279
Planned patient activity
Patients will have access to multi-purpose group/therapy areas to participate
in a range of therapies. For instance:
Dietetics
•
•
•
Access to support cluster areas for one-to-one consultations 3-4
times per week
Access larger rooms to conduct group sessions. X3 per week in
clusters
Access to patient kitchen such as ADL Kitchen areas for provision of
community food work service x1 per month.
Occupational Therapy
•
•
•
•
Access to outdoor area for horticulture
Access to larger rooms to conduct therapeutic group sessions with
option of partitioning this to enable separate group sessions to take
place
Access to ADL kitchen for assessment and individual and group
treatments ( ensuring there is sufficient space for dining)
Access to consulting room/quiet rooms for individual OT assessments
within designated ward area/cluster recognising some areas are
restricted with locked door
•
Physiotherapy
•
•
•
Access to fitness suite and group room for exercise programmes
(individual or group). Daily if possible. 1-2 hours
Access to consulting room 2-3 x weekly 1 hour
Some groups eg relaxation/mindfulness could be delivered either in a
room in one of the clusters or ECT suite when available.
280
General principles of operation
Design Synopsis
Maximise use of natural light.
Disability Discrimination Act compliant
Occasional seating in corridors for patients to rest.
Seated areas for quiet contemplation
Link with Adult mental Health Wards (AMH) and Intensive Psychiatric Care
Unit (IPCU) wards
Maximum use of natural and artificial ventilation
Clinical areas that are non threatening and welcoming
Common sitting and activity areas should be homely and domestic while
lending themselves to recovery and should not be open plan
Adequate signage should be provided from the ward area to the support
clusters
All areas within the support clusters should be easily observable with no
blind spots
There should be one single point of entry to the support cluster, access
procedure – depending on patient group ( open and closed environments)
Should be a ligature free environment
Corridors: Required features
Maximise use of natural light.
DDA compliant
Hand Rails required, for individuals with reduced mobility Definitely
required in Elderly areas and rehab
occasional seating required for patients to rest .
•
Wide capacity – to take 2 way traffic, for instance, wheelchairs/walking
aids/supervise those with reduced mobility
Mixed gender requirements
The design must comply with current guidance and legislation
Disabled access requirements
Must be DDA compliant, including loop system.
281
Privacy and dignity requirements
The design of the unit must comply with current legislation
Number and types of rooms
The schedule of Accommodation provides further information on rooms.
Required adjacencies
External
All support clusters should be adjacent to the wards that will be accessing
the facilities.
The support cluster should be an enclosed, safe and stimulating space
Internal
Clean and Dirty utility room and store room should be away from the main
therapy area
Storage facilities
The following storage facilities are required for:
•
Equipment used in the group/therapy area
Anticipated developments
The building should be able to meet the needs of future Information
Technology developments
The building should be flexible in design to meet the challenges of an ever
changing and improving Health Service
Client Group Characteristics
282
Age and Gender
Support Cluster 1 – 16 to 65 years of age
Support Cluster 2 – 16 to 65 years of age
Support Cluster 3 – 65 years and over
Male and female
Admission Rates
Not applicable
Diagnoses
Support Cluster 1
•
Patients accessing this cluster will have a varying range of mental
health problems/illness and may experience issues re drug/alcohol
misuse
Support Cluster 2
•
Patients accessing this support cluster will suffer from an identifiable
mental disorder, have a varying range of mental health
problems/illness and may experience issues with drug/alcohol misuse
Support Cluster 3
•
Patients accessing this cluster will have been diagnosed with an
identifiable mental disorder and have general geriatric medical
conditions
283
Anticipated illness-related behaviours
Support Cluster 1
•
•
•
•
•
•
•
•
•
•
Aggressive behaviour (verbal and physical)
Aimless or ritualistic behaviours
Disinhibited behaviours
Lack of personal risk awareness
Suicide risk
Unpredictable and impulsive behaviours
Secondary physical disabilities/illnesses
Fear and apprehension
Patients from the IPCU ward are more likely to have complex needs,
including resistant psychotic illness, disadvantaged socioeconomic
background and co-morbid substance abuse problems, compared
with the patient population of general adult mental health services
Serious assaultative behaviour
Support Cluster 2
•
Relapse and breakthrough symptoms
Support Cluster 3
•
•
•
•
•
•
•
•
•
•
•
•
•
Confusion
Aimless behaviour
Wandering
Aggressive behaviour, both verbal and/or physical
Disinhibited Behaviour
Physical inactivity
Withdrawn
Suicidal
Lack of self confidence
Secondary physical disabilities/illnesses – malnourished
Unsteady gait - Risk of falling
Anxious
Paranoid/suspicious
284
Anticipated clinical risks
Patients who access these support clusters may be at risk from the
following:
Support Cluster 1
•
•
•
•
•
•
•
•
•
•
Deliberate self harm
Harm to others
Poor motivation
Self neglect
Suicidal intention
Isolation in a community environment (social breakdown)
Institutionalisation
Absconding with associated risks
Challenging behaviour
Disinhibited behaviour
Support Cluster 2
•
•
•
All of the above
Obesity
Inactivity
Support Cluster 3
•
•
•
•
•
•
•
Poor physical health and related physical dependency
Poor mobility
Risk of falling
Poor motivation
Delayed discharge
Reduced ability to self care
Isolation/institutionalisation
285
Patient dependency characteristics
Therapeutic Intent
Inpatient care is one element of the care pathway. It offers time limited
safety, support and therapy to people who are too unwell to be cared for in a
non hospital setting. It is to improve the person’s mental and physical health
and functioning.
All clinical, therapeutic and social care will be provided at the least restrictive
level appropriate to the needs of the client group.
For some patients requiring long-term continuing care the ward is their
home.
Principal aims of clinical care
Therapies
•
•
•
•
•
•
•
Individual and group therapies will be provided in the support cluster
on a planned and ad hoc basis
Therapies will enhance the care experience and will be focussed
upon specific agreed interventions and outcomes
Therapy should be in keeping with recovery/Tidal Model and should
be evidence based
Therapies should be provided by a wide range of multi disciplinary
staff and other agreed partners
Therapy Examples – Anger management, Coping Skills, Anxiety
management, ‘talking therapies’ & engagement, ADL skills
Individual and group therapies will be provided on a planned and adhoc basis
Therapies will enhance the care experience and be focussed on
specific interventions and outcomes
Therapeutic facilities required
•
•
•
Adequate space to provide therapeutic interventions as required
within the units both as groups and 1-1
Adequate storage space to contain therapeutic equipment will be
required within the units
Sufficient space for physical activities and exercise
286
•
Suitable furniture/fixtures and fittings to support activities (including
facilities for the art group)
Planned clinical meetings
•
It is not anticipated that clinical meetings will take place within the
support clusters.
Other Meetings
It is not anticipated that any other meetings will take place within the support
clusters.
Clinical risk management principles
•
•
•
•
•
•
Risk management for this client group is important. The environment
must be conducive to delivering the risk management plan
Based on a proactive approach to positive risk management
(embedded within the service)
Formalised assessment tools will be utilised and process reviewed on
an ongoing individualised basis
On admission each patient is assessed in accordance with a
recognised risk assessment tool
Based on this initial risk management plan is developed which will
also determine the person’ observation status
The IPCU ward will have systems and processes, from the preadmission stage through to aftercare, that ensure the multidisciplinary assessment of the health and social care needs of
patients, and the risk of harm posed by them to themselves and
others. Assessments will then be used to inform the treatment plan
and enhanced Care Programme Approach.
Operational Procedures
Working day plans
•
•
•
It is anticipated that each cluster should be accessible as required
and into the evenings, 7 days/week
On occasion there may be a requirement for access to the multipurpose group therapy area for evening social events.
On occasion there may be a requirement for access to ADL kitchen
for breakfast and early evening activities
Staffing arrangements and shift patterns
287
Patients will in the majority of cases be accompanied by members of staff
when using the support clusters.
Admission procedures
Not applicable
Record-keeping storage
Lockable storage facility
IT infrastructure and full range of appropriate systems
Visiting arrangements
•
Not applicable
Mealtimes/dining arrangements
•
•
Support Cluster 3 has a pantry associated with the multi-purpose
group/therapy area.
The other support clusters do not have any provision for
mealtimes/dining arrangements.
Between meal snacks and access to beverages
Support Cluster 3 will provide meals snacks or beverages throughout the
day
Support Clusters 1 and 2 have no provision for meal snacks or beverages
Laundry facilities and linen management
Not applicable
Recreational Facility
•
•
•
TV areas, quiet areas, activity areas,
The multi-purpose group/therapy area will be used as a large social
gathering area for large functions eg concerts/bingo/bowls/teas
Patient computer/internet/e-mail access could be available in this
cluster as increasing number of patients will be computer literate
288
Functional content
Number of Inpatient Beds/Treatment Spaces
•
No inpatient beds are provided in any support cluster.
Investigative/Diagnostic/Treatment Capacity:
•
Not applicable
Outpatient Service (Number of Sessions and
specialist functions):
•
Not applicable
Specialist Technical Infrastructure Requirements
•
No specialist technical infrastructure will be required in the support
clusters
Projected Future Activity
•
Not applicable
Key Relationships with Other Departments/NHS
Ayrshire and Arran /Social Services/Social
Work/Local Authority Services
•
Not applicable
289
Future Service Delivery Risks
•
•
•
•
•
•
•
•
Access to essential supporting services/facilities/people;
Health & Safety (anti-ligature);
Throughput activity/case mix change;
Changes in practice;
Ageing population – more elderly patients;
Demographic changes;
Activity levels unpredictable; and
Future service demand is uncertain. This new provision needs to
reflect change in trends and be adaptable to future need.
290
Appendix 2C
Environmental Quality Report
ENVIRONMENTAL QUALITY
1. Background
The built environment that this business case relates to includes
accommodation that is currently delivered from three separate hospital sites.
These are:
•
•
•
Large components of the Ayrshire Central Hospital (ACH) Site. (By far
the largest component of this business case.
Retained clinical components of the Ailsa Hospital site (Primarily a
refurbishment of elderly ward areas to bring them to a similar level of
clinical functionality as the new build at ACH but also to extend the
lifespan of their services
The relocation of Wards 1d and 1e (Acute mental health wards) and
Clinic K, Crosshouse Hospital will support NHS Ayrshire & Arran’s
“Building For Better Care” project.
Relevant elements of these facilities is now considered in more detail.
2. Ayrshire Central Hospital: Relevant Site Overview
Ayrshire Central Hospital (ACH) is located on the Western outskirts of Irvine
in North Ayrshire. Although originally constructed in 1941, the site layout has
changed very little thereafter.
Originally the Hospital provided in-patient care for infectious diseases and
maternity services for the whole of Ayrshire and was split into North and
South sections.
Historically, the nine pavilions to the North of the site (See Figure 1)
provided 276 beds for infectious diseases, with the Southern end of the site
providing a further 160 beds for maternity and post natal care.
Following a region wide review of clinical service delivery, maternity moved
from the Ayrshire Central site to Crosshouse Hospital in August 2006,
leading to the demolition of the old maternity building in early 2007 and the
subsequent closure of the nurse’s residency building, which was no longer
required.
Over a period of time these changes have led to a situation where the ACH
site has been impacted upon by a wide range of service-related decisions
that have primarily seen services move away, in turn this has led to a
situation where the existing facility has suffered from a lack of overarching
strategic direction/planning with a subsequent reduction in investment and
co-ordination.
1
At present, the majority of clinical accommodation is still delivered from a
combination of the original 1941 non-linked “pavilions”, supplemented by
some non-linked 1970’s/80’s accommodation, e.g. Garnock Day Hospital.
Each inpatient pavilion features between 18 and 30 beds. All of this is in
mixed sex wards that are divided into separate male and female multi-bed
rooms. These bedded areas are supported by day space and minimal
therapy areas within each individual building.
Figure 1: Existing Ayrshire Central site
Pavilions 4-6
Pavilions 7-9
Pavilions 10
&11
Nurse’s
Residency
Building
Pavilions 1-3
New Kitchen &
Dining Room
Douglas Grant
Rehabilitation
Centre
Mammography
Extension
Out-patients
Porter’s lodge
& New GUM
Horseshoe
Building
Specifically, existing inpatient services (including short stay rehabilitation
and continuing care beds) are delivered from five pavilions as follows:
Pavilion 1
Pavilion 2
Pavilion 3
Pavilion 5
Pavilion 6
18 short stay rehabilitation beds
18 short stay rehabilitation beds
25 short stay rehabilitation beds and 4 respite beds
30 continuing care beds
30 continuing care beds
The remaining 4 pavilions which are due to be demolished to make way for
the new hospital, provide a variety services for the site and the surrounding
locality:
Pavilion 4 - Learning Disability Service & Child and Adolescent Mental
Health, plus a local authority day service (Carepoint).
Pavilion 7 - Community Clinical Psychology Service and Speech &
Language Service.
Pavilion 8 - North Ayrshire Community Health Partnership.
2
Pavilion 9 currently accommodates a number of Local Authority and
voluntary services, including Ayrshire Independent Living Network,
Specialist Huntington’s Disease Ayrshire Service and Momentum Scotland’s
Pathways Ayrshire programme.
Other accommodation/services currently delivered from the ACH site
include:
Within the Horseshoe building:
• General outpatients include 6 consulting rooms and 5 interview rooms
(these have recently been refurbished to meet clinical psychology and
community mental health standards), nail surgery and podiatry.
• A new outpatient department extension – linked to the existing OP
department provides 6 further consulting rooms, an additional minor
operations room, treatment room, quiet room and interview room.
• A diagnostic department includes 2 x-ray rooms with associated
accommodation i.e. waiting room, reception, process/viewing room and
film chemical store.
• Mammography, including 2 mammography rooms and associated
accommodation.
• Community dental, including 6 community dental surgeries and 1 x special
needs dental surgery.
• A range of further supporting clinical accommodation on the ground floor,
including AHP treatment, gymnasium areas and Ayrshire Doctors On-Call
(ADOC) clinical consulting and support accommodation.
• A range of administrative and meeting areas on the first floor, providing a
mixture of non-clinical office and service spaces.
Within the Douglas Grant Rehabilitation Facility and associated Pavilions
(10 and11):
• Stroke rehabilitation in-patient services
• neuro-rehabilitation in-patient services
• NHSA&A outpatient and day case centre for neuro-rehabilitation services
Within the new kitchen development:
• The production kitchen (servicing the meal requirements for the entire site)
which has been sized to accommodate future requirements associated
with this development.
• The main staff and public dining areas
Within the new Clinical Decontamination Unit:
• TSSU services for all of NHS Ayrshire & Arran and surrounding Board
areas
3
A range of smaller buildings that do not feature substantially within this
business case but that are significant to the site include:
•
•
•
•
Eglinton GP Practice
New GUM (Genito-Urinary Medicine Clinic/Sexual Health) clinic facility
Patient’s personal laundry facility
Procurement offices/delivery area
3. Ailsa Hospital Campus: Relevant Site Overview
It is currently anticipated that much of the existing estate will be retained at
Ailsa Hospital; however this business case only covers investment in the
clinical (ward) areas being retained. (The remaining clinical accommodation
will be transferred to the new NACH facility). Figure 2 provides a site plan of
Ailsa Hospital.
Clinical areas being retained that will be invested in include:
• Lewis, a 9 bed dementia care ward
• Iona, a 12 bed dementia care ward
• Jura, a 21 bed dementia care ward
• Dunure, a 22 bed organic assessment ward
• Clonbeith, a 16 bed continuing care (functional) ward
• Croy, a 14 bed functional assessment ward
• Croy day hospital
Lewis, Iona and Jura are configured as one wing of a single building
complex with Dunure and Clonbeith forming the other wing. These two
wings currently share a central gym/therapy area that it is not anticipated will
change physically as a result of any new proposals for the Ailsa Campus.
Croy is located in a separate but adjacent building which features a day
hospital area that will not be affected physically by any new proposals for
the Ailsa campus.
It should be recognised that these wards are already physically remote from
other buildings on the site and that their relationship will not change with the
remainder of the retained estate.
Other clinical areas that will transfer from the main hospital block at Ailsa to
the new NACH facility include:
• Albany ward, a 8 bedded non acute mental health ward
• Cloncaird ward, a 8 bedded ward
• Killochan ward, a 12 bedded ward
• Ballantrae ward a 10 bedded ward
• Glenapp ward a 12 bedded rehab ward
• Ardlochan ward, independent living facilities
4
Figure 2: Ailsa Hospital, site plan
Iona, Lewis and
Jura Wards
IPCU
Clonbeith
& Dunure
Wards
Main Block
including:
Cloncaird/
Crossraguel
Killochan
Ballantrae
Glenapp
Ardlochan
Tribunal
Suite
Loudoun
House
Croy Day
Hospital
Kyle & Park Wards
(including ECT
Suite)
Albany
Ward
4. Crosshouse Hospital Campus & Kilmarnock Area: Relevant Site
Overview
Located just to the east of the East Ayrshire village of Crosshouse and 1¼
miles (2 km) west of Kilmarnock, Crosshouse Hospital is the principal
general hospital in North and East Ayrshire. Crosshouse was officially
opened by the Secretary of State for Scotland, George Younger (19791986) on 2nd June 1984.
The hospital has 636 beds and includes accident and emergency facilities
and Adult general psychiatric in-patient services (46 beds) that are provided
in two wards in Crosshouse Hospital 1D and 1E.
Current Mental Health accommodation at Crosshouse Hospital that is
relevant to this business case includes:
•
•
•
Ward 1D, -23 bedded acute mental health admission ward
Ward 1E, -23 bedded acute mental health admission ward
Clinic K
It is planned that all of the above will transfer to the new facility at Ayrshire
Central Hospital, see Figure 3 showing Crosshouse site plan.
5
Figure 3: Crosshouse Hospital, site plan
Wards 1D
& 1E
Clinic K
5. Environmental Considerations (6 Dimensions of Quality)
In considering the accommodation impacted upon by this business case, its
overall performance has been assessed against the six dimensions of
quality outlined in Better Health, Better Care and subsequently cited in the
recently launched National Quality Strategy. These dimensions are:
Patient
centred
Safe
Effective
Efficient
Equitable
Timely
Its ability to provide care that is responsive to individual patient
preferences, needs and values and assuring that patient values
guide all clinical decisions
How it supports the avoidance of injuries to patients from care
that is intended to help them
How it provides services that are evidence-based
How it avoids waste, including waste of equipment, supplies,
ideas, and energy
How it supports care delivery that does not vary in quality
because of personal characteristics such as gender, ethnicity,
geographic location or socio-economic status
How it can reduce waits and sometimes harmful delays for both
those who receive care and those who give care
6
A summary of this assessment follows that highlights current environmental
quality issues that impact on service delivery as well as how they will be
addressed by the investment proposed within the business case.
5.1 “Patient Centred” Issues Current
NHS Ayrshire & Arran’s commitment to patient centred care which is
respectful, compassionate and responsive to individual patient preferences
is well documented in its annual service review assessments. It is very
challenging to meet this commitment through the quality of our built
environment.
Ayrshire Central Hospital
The ward and building configuration of the pavilions does not promote
patient choice, patient observation or patient engagement. Ill patients often
have to share six bedded dormitories and such single rooms as exist are
often in cramped conditions that fall significantly short of current space
standards.
Of the 125 beds within the 5 pavilions, only 8 are single room with en suite just over 6% of the overall bed compliment. This is well below current
Scottish Government guidelines and lower than the overall 32.5% single bed
provision for NHS Ayrshire & Arran as a whole.
The current guidance outlined in CEL 27 (2010) for the provision of single
room accommodation and bed spacing states that the minimum required
bed space should “not be less than 3.6m wide x 3.7m deep”.
7
Figure 4: Ayrshire Central ward and toilet layout
Of the 8 single bedrooms in Ayrshire Central hospital none meet the current
guidelines with an average single bedroom size of 3.4m wide x 3 m deep or
less.
In summary, the site currently has zero single bed accommodation that
meets minimum current standards.
All of the in patient ward accommodation at ACH is mixed sex although
individual ward rooms are single sex. Figure 5 shows Pavilion 1 layout This
issue is closely aligned to the privacy and dignity of the patient (Department
of Health, 2007). Other issues of concern with the current environment
include:
• The difficulty associated with keeping the facility clean, and appearing
clean to patients and visitors, in reflection of the poor state of much of the
environment as highlighted by the National Cleaning Standards published
relating to the site;
• The requirement to use commodes because of the inaccessibility of many
ward toilets (including en-suites);
• The difficulties associated with conducting clinical conversations in
private;
• The requirement for male and female patients to share support
facilities/areas, e.g. Day spaces, toilets, shower areas, etc;
• Having access to private toilet/washing facilities;
8
• The ability to entertain visitors in private areas/bedrooms when
appropriate; and
• Having a degree of autonomy and control over environmental conditions,
for example. being able to close blinds, shut doors, alter temperatures, etc.
Within the pavilions it is very difficult for patients to access private space as
the communal space at either end of the pavilions is large and difficult to
supervise.
4 bedded wards
4 bedded
ward
Sitting Room
2 bedded
ward
Day Room
Bathroom
Bathroom
Staff room
Treatment
Room
Physiotherapy
Ailsa Campus
The majority of Acute Mental Health Wards (AMH) in Ailsa Hospital are
situated within the main block which was constructed in the early 1868 of
sandstone block and has very similar issues to those at the existing ACH.
The AMH wards include Albany, Cloncaird, Killochan, Ballantrae, Glenapp
and Ardlochan which is the Independent living assessment area. With the
exception of Albany these clinical areas are situated within the main block.
Albany and Ardlochan wards are the only ward areas that are solely ground
floor accommodation – providing an additional challenge to effective patientcentred care delivery.
9
The accommodation is mixed sex single bed accommodation that varies in
size from 6.5m² to 19.1m² with no en-suite provision. The same issues
apply to Ailsa as exist at ACH
Within the AMH wards there is poor lines of sight and, although all
bedrooms are single, there is very little scope to adjust the current built
environment to meet an individual’s needs.
Elderly ward areas at Ailsa include Lewis, Iona, Jura, Dunure and Clonbeith.
Lewis, Iona and Jura are configured as one wing of a single building
complex with Dunure and Clonbeith the other wing. These two wings
currently share a central gym/therapy area that it is not anticipated will
change physically as a result of any new proposals for the Ailsa Campus.
Within the elderly mental health ward areas day space areas and bedroom
sizes are acceptable, although en-suite accommodation is configured such
that dual assistance is difficult to realise – meaning that all patients who
require dual assistance are currently taken to the appropriate assisted
bathroom. (The shower is a separate cubicle with curtain and wall rather
than the more modern style “wet room” type facility),
Storage space is highly limited in all ward areas with the result that not all
rooms can be used for their primary function effectively because of the
volume of inappropriately stored goods/materials they contain. E.g. dirty
utility rooms are full of items because there is no space to store them
elsewhere).
In addition, Lewis and Iona wards were previously a single clinical unit that
has been separated to provide segregated facilities for different patient
groups with particular care needs. Consequently these wards do not have
access to all of the areas that they would ideally; most notably the existing
single dirty utility and assisted bathroom is shared between the two which is
deemed to be unacceptable.
Being of a very deep plan form, the central component of the ward areas –
which includes the day spaces where patients spend most of their time, has
only limited access to natural light. Although these central core areas do
have “skylights”, some of which have been enlarged to try and improve this
situation, they are far from ideal and more natural light in day spaces is
highly desirable. (Not least as it is an aid to orientation for the patients who
reside here)
10
The Intensive Psychiatric Care Unit (IPCU) is located on Ailsa campus in a
building which was formerly office accommodation for Consultant
Psychiatrists and Medical Records. Although this area provides all single
bedded accommodation (7 beds) it is a very confined area and there are
many challenges in maintaining a safe environment due to its layout, for
instance:
• Increased levels of observations to ensure safety;
• Very limited access to public and recreational space, which constrains
recreational and therapeutic activities;
• There is a very limited ‘garden space’. What is provided is a concrete
courtyard with some raised flower beds to try and afford some green
space;
• The entrance to the building is dark and unwelcoming and the interior of
the building is ageing with little natural light; and
• There are blind spots within the bedrooms and general areas of the ward
which pose a risk to the safe running of the Unit.
The IPCU building is located at the other end of the site from Kyle/Park and
individuals who require to be transferred to IPCU have to be escorted
through the grounds. This does not preserve the individual’s privacy and
dignity, particularly if requiring physical restraint. The situation is made
worse for those patients being transferred from 1D/1E at Crosshouse as this
necessitates a 19 mile ambulance journey with the associated risks for
patients and staff.
Kyle and Park at Ailsa is a 23 bedded acute adult admission ward that was
designed and opened in the late 1980’s. The bed complement comprises of
5 single en-suite rooms and 3 x 6 bedded dormitories.
The entrance to Kyle/Park can be quite busy as it is also co-located with outpatient clinics and the ECT clinic. There is no dedicated space for
admissions and therefore there can be a lack of privacy individuals being
admitted and their families/friends.
Crosshouse Hospital & Kilmarnock
The AMH wards within Crosshouse General Hospital (wards 1d and 1e)
were originally designed to meet the needs of a physically unwell client
group rather than those with mental health issues and consequently the
layout does not lend itself to the safe observation of individuals with
thoughts of self-harm, this in turn leads to a requirement for increased
staffing levels to ensure the safety of the patient with the associated
restrictions and perceived intrusion.
11
Both 1D & 1E are 23 bedded wards - only 5 beds in each ward are single
en-suite rooms, the other 18 beds in each ward are 6 bedded dormitories,
there are no gender specific public areas. There is no designated outside
space on Crosshouse Campus for individuals from 1D/1E and there is a
high volume of traffic on the site. Those being cared for within 1D/1E can
feel very constrained, in wards that are not designed to meet their needs
and with little access to green space. In addition they find themselves
located within the centre of a busy acute general hospital facility that is
frequently not in keeping with their care requirements.
Patient Centred Considerations: Proposed
NHS Ayrshire & Arran’s vision for the future direction of clinical services
delivery was approved by the NHS Board in November 2008, and updated
in December 2009 when the Board approved the Primary Care Your Health
Strategy.
This vision is based on shifting the balance of care from hospital to
community based delivery (including community hospitals and community
treatment centres) wherever safe and practical to do so. The new facility will
enable a range of planned care services to be developed locally, ensuring
that it is seen as a local community resource centre providing a bridge
between home and acute hospital care.
The new build component of the NACH will include:
• A main (outpatient) entrance with reception areas, waiting space,
security/porters accommodation, café, small retail outlet, toilets, spiritual
care area and changing facilities;
• An in-patient entrance to support the admission/transfer-in of patients on
trolleys/chairs (avoiding main public thoroughfares);
• Outpatient clinic/consultation areas configured as a range of interconnected but self-contained “modules” to support the full range of mental
health, psychology-related and Learning Disabilities Service OP/consulting
activity on the site including 2 “counselling clusters” and a “Child and
Adolescent counselling cluster” – each with circa 6 consulting rooms per
cluster. It is noted that “general out patient consulting” will continue to
occur within the existing and extended outpatient department although
there will also be a “cross-over” in activity terms between the two areas;
• An ECT/Minor surgical/outpatient area (re-located from Ailsa Hospital),
located close to elderly mental health wards and outpatient areas, with
treatment and recovery spaces that would also be used as clinic
accommodation for AHP services and as a minor surgical procedures
area. (Functions changing on a sessional basis);
• A pharmacy/dispensary area; and
12
• A meeting/tribunal area which will relocate from Crosshouse and Ailsa
Hospitals that is easily accessible from the main “core” of the facility that
can be used as meeting rooms when not being utilised for tribunals.
In-patient ward areas arranged in 3 clinically appropriate “clusters” around
shared support areas including:
• Cluster 1; 88 Acute mental health beds in 3 wards and an 8 bedded
Intensive Psychiatric Care Unit (IPCU) & 10 low secure beds
• Cluster 2; 30 Non acute mental health beds, 15 addictions beds, 12 rehab
in-patient beds,
• Cluster 3; 30 elderly mental health beds in 2 wards, 30 long-term
(continuing) care beds and 30 rehabilitation beds
It is noted, that in developing the operational model for the facility, a number
of principles have been established that will be recognised in the design,
layout and configuration of the new estate and how it relates to
existing/retained buildings. These include that:
• Wards will be configured in identified “clusters” in line with the massing
diagram, each cluster supports a small range of local services and
accommodation.
• All 254 in-patient bedrooms will comply with the current CEL 27 (2010)
guideline and address the whole patient experience at ACH, by a 100%
improvement of issues such as privacy and dignity.
An essential part of the development of the ACH site is access to safe
external landscapes and as such key landscape elements of the site will
include
• Provision of a landscape led unifying framework and structure for the
development proposals to ensure a consistent and cohesive approach to
the site and to ensure an appropriate therapeutic and healing landscape
suitable for the sites role as a mental health and community hospital
• Taking cognisance of the existing landscape and built environment and
protect and augment them in the new proposal
• Creating a high quality, attractive and diverse hard and soft landscape
treatment that reflects the status of the development complements the
architecture of the building and strengthens the existing landscape
character.
• Provision of a hierarchy of public and private spaces and their appropriate
landscape treatment.
• Provision of a rich and inspirational environment, with seasonal interest
and attractive usable spaces for all users including hospital staff, patients
and the community
• The soft landscape design and choice of species that will be sympathetic
to the character of the existing landscape and enhance the existing
woodlands without affecting the long term integrity of the same.
• Access to Private Courtyards from ward areas
13
• The Woodland Belt and Public Open Space
• Car Parking and Vehicular Movement Zones
All clinical consultations at the new NACH will take place in designated
consulting areas that will be separate from staff offices and support the 3 tier
AHP model that has been proposed:
• 1st tier – the ability to support patients in their own room;
• 2nd tier – the ability to support patients in a therapy/communal space within
the ward; and
• 3rd tier – the ability to support patients in scheduled space within the
clusters or externally.
Further clinical consultation areas will include the existing general and
diagnostic outpatient departments within the Horseshoe building, the new
consultation areas specified within the schedules of accommodation for
mental health/psychology/LDS/Etc, related services (including children’s
services) and identified consulting space within wards and support
“clusters”.
Staff will use the new dining room that has recently been constructed for all
meals and breaks.
The new kitchen area will service all meal requirements throughout the site.
Ailsa Campus
Relocating the adult acute admission accommodation will realise the vision
for shifting the balance of care from hospital to community based delivery.
Currently the bed configuration is stretched across the length of the building
which is not conducive to good levels of observation. There are various blind
spots which present dangers to both staff and patients in the buildings.
Corridors are dark and only allow limited natural light to enter the building.
There is one very small Treatment Room which is not fit for purpose. There
is no green area for patients to access, instead there is a patio area that
receives very little light and is very claustrophobic.
The new build IPCU will be design specifically for the purpose it was meant
to serve and in doing so will address the majority if not all the issues
previously discussed. In addition it will provide accommodation that is light,
airy and afford far greater opportunity regarding access to green space,
therapeutic activities, space for families to visit etc. It would be co-located
with the adult acute admission wards and will allow discrete access.
14
The proposed model for the new-build non-acute accommodation is to have
a 30 bedded ‘Slow Stream Rehabilitation Unit’ provided on a single en-suite
room basis. The Unit would be sub-divided into smaller ‘pods’ that would
allow gender and condition specific adaptation to ensure the provision of
individualised person-centred care.
The ‘Fast Track’ Rehabilitation Unit will have 12 beds, again all single and
en-suite but 3 of these beds will be within single self-contained bed-sit type
accommodation to allow individuals to practice independent living skills prior
to discharge.
Crosshouse
Wards 1d and 1e (Acute mental health wards), Clinic K, the ECT suite and
tribunal accommodation at Crosshouse Hospital will be transferred to the
new build at ACH – freeing up space for the redesign of “front door services”
under NHS Ayrshire & Arran’s “Building For Better Care” project.
Safety Issues Current
There are a number of issues that pertain to the safe environmental quality
of all three Hospital sites, these can be summarised as follows:
•
•
•
•
•
•
Observing and engaging with patients is hampered by the design and
layout of the wards;
Inadequate space in all ward areas to provide quiet areas for patients;
Ageing accommodation and site layout creates increasing health &
safety concerns for patients and staff;
Current accommodation does not allow for ward and therapy areas to be
closely connected;
Service Users have to walk through busy corridors or be transferred by
ambulance through the grounds to access services or therapies –
exposing them to the risk of foot and road traffic; and
The nature of the existing estate makes extensive works regarding antiligature issues financially unviable with the associated risks.
Ayrshire Central
It is crucial to have an environment which supports the very highest control
of infection standards. With an efficient design, the management of
Healthcare Acquired Infection policies can be optimised. The table below
illustrates the number of ward closures and incidences of HCAI over all
three hospital sites.(see Figure 6 Source:- NHS Ayrshire & Arran’s Control
of infection Team)
15
Figure 6: Infection Control instances [March 2009 – March 2010
Ayrshire Central
Hospital
Pavilion 1
Pavilion 2
Pavilion 3
Pavilion 5
Pavilion6
Total
Ailsa Campus
Clonbieth
Dunure
Brodick A
Brodick B
Croy
Total
Crosshouse Hospital
1D
1E
Total
Ward Closure
3
0
2
3
3
11
1
2
1
1
0
5
Incidences of
HAI
8
1
108
50
27
94
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Ailsa Campus
Fire Risk Assessment
• A recent fire risk assessment carried out at Ailsa Hospital found the
general fire precautions within Clonbeith & Dunure, Iona, Lewis, Jura
Wards and Croy ward and Croy Day Hospital were found to be adequate
and in general all the ward areas were assessed as being level 9, which
is low risk, although the report identified a number of operational issues
which are being addressed.
Estate constraints
Throughout the adult acute admission and IPCU setting there are
challenges with regard to safe observations, ligature risk and generally an
environment in which staff have to work extremely hard to overcome the
challenges of the environment rather than having it assist them in the safe
and effective delivery of care.
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The current non-acute estate is of mixed quality, outdated, and no longer
suits current modern nursing approaches and practice. The Victorian estate
offers no flexibility in re-configuration, and the physical spread of wards does
not support an integrated approach to care delivery. As already mentioned
the bulk of the accommodation is over more than one floor and this poses
challenges regarding those individuals with physical mobility issues or
sensory impairment.
The nature of the existing estate makes extensive works re anti-ligature
issues financially unviable with the associated risks.
Safety Considerations Proposed
The general principals and considerations of safety outlined within this
section will be expected within the new facility. For instance:
• The overall design and layout of all areas will aim to reduce the risk of
harm to patients and staff and provide a safe environment. Key elements
of this risk reduction strategy will include, but not be restricted to:
o Ligature points being avoided in all clinical/common areas
through the selection of fittings and materials that reduce
risk;
o Door handles must not have thumbscrews;
o The clinician should be positioned closest to the exit door of
the room when consulting with or treating a patient;
o Consideration will be given to lighting at bed positions;
o Sharp edges will be avoided;
o Wall mounted items of equipment such as fire extinguishers
will be recessed to prevent damage;
o Wall / door protectors will be used where there is risk of
damage from e.g. bed / trolley movement;
o In addition, it will be possible for staff to lock-off en-suites
and manually override any locks applied by patients as
appropriate;
o Control of infection issues remain extremely important
considerations with Domestic Services Rooms (DSR or
“Cleaners rooms”), linen areas, clean utility rooms and dirty
utility rooms specified in all areas. Whilst efficient design may
allow some appropriate sharing of these facilities, the design
will always optimise the control and management of
Healthcare Acquired Infection in line with all relevant
guidance on this matter, most notably in line with HAI
SCRIBE; and
o Staff will continue to change in a range of established
changing areas throughout the site although additional
changing facilities have also been scheduled into the new
build. All changing is based on a model that will see staff
only having access to lockers for the period of a shift/duty in
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line with current thinking on this issue and to ensure optimal
use of all areas.
The new facility will address a number of issues and criticisms of the current
accommodation, such as:
o Safe levels of medical cover 24 hours a day, seven days a
week;
o Purpose built facilities that will ensure a high level of safety
measures incorporated into the build, including good
observation and engagement features;
o New build accommodation will allow for ward and therapy
areas to be interconnected;
o Appropriate accommodation will ensure ample quiet areas to
help reduce tension for individuals and groups;
o Improved safety at night for patients and staff;
o More staff available to call upon in emergency situations;
and
o Location in North Ayrshire means the majority of emergency
admissions having less distance to travel from North and
East Ayrshire.
Effective Current Estate
Ayrshire Central
A recent inspection of the Mental Health Welfare Commission commented
about the Pavilions at Ayrshire Central:
• “Despite some refurbishment, these wards remain unfit for the care of
people with dementia and there is no clear reprovision plan”.
• “The physical environment is poor and unfit for purpose. The ward has a
mix of people with differing needs and we thought the staff numbers, skills,
training and supervision were not adequate to provide proper care”.
• Physical Health Care: “Regular physical health reviews and provision of
appropriate documentation of incapacity need to improve”.
• Activity: “Availability of activity was variable. The service needs to ensure
that all people have access to appropriate stimulation and useful activity”.
In conclusion the team stated that “The accommodation is not fit for purpose
and there are issues about the mixing of young physically disabled patients
and continuing care patients. The pavilions also have very large day/dining
rooms, lack of storage space and inadequate space between the beds. This
hospital requires major refurbishment to bring the accommodation up to
modern standards”.
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Ailsa
The current accommodation is out-dated and is no longer fit for purpose
given numerous recent changes and future anticipated changes;
• Recent and projected increase in forensic and dual diagnosis in
population;
• Personality disorder with challenging behaviours, ARBD population;
• Impact of Mental Health (Care & Treatment)(Scotland) Act 2003 and
Section 26 re Social Inclusion and associated responsibilities;
• Emphasis on Recovery agenda and focus on rehabilitation;
• Healthy living lifestyle, physical health and activity;
• Condition management;
• Ageing population – more elderly patients, demographics; and
• Move away from ethos of ‘Continuing Care’ to ‘non-acute’, always looking
to individual moving on from in-patient care.
Staff currently strive to provide the best clinical care in environments that do
not lend themselves to individual, therapeutic rehabilitative function thereby
reducing their effectiveness.
Effective Considerations Proposed
The general principals and considerations of effectiveness outlined within
this section will apply to the new development:
• the new development will develop new services and models of care. A
Clinical Options Group, set up to ascertain current clinical activity and
proposed services to be delivered from the new hospital has identified the
need to expand the range of services currently on offer and to review the
ways that these are delivered effectively. Although much of this can be
achieved through more detailed analysis of existing services and
operational re-configuration, an element of new build is required to support
future capacity requirements and approved clinical strategies, such as:
o Helping people to sustain and improve their health,
especially in disadvantaged communities, ensuring better,
local and faster access to health care;
o Helping local communities to flourish, becoming stronger,
safer places to live, offering improved opportunities and a
better quality of life;
o Supporting teaching and training; and
o Rationalising the existing estate in order to improve
operational efficiency, communication, accessibility, etc.
The proposed accommodation for the new facility will be more flexible,
support individualised therapeutic activity, optimise the effectiveness of staff
interventions and have a greater impact on the quality of care delivered in
order that staff time and effort can be utilised more effectively to overcome
the shortcomings of the built environment.
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Efficient Current
Ayrshire Central
As already stated, most buildings on the Ayrshire Central site are ageing,
functionally unsuitable and in poor physical condition, constraining the ability
for further clinical development. Specifically, in the Board’s current 6 facet
survey, Ayrshire Central Hospital is listed as Estate Code category C (below
acceptable standards) for functional suitability and category 3 (adequate) for
space utilisation. Figure 7 shows further detail on the 6 facet report.
Figure 7: 6 Facet information for Ayrshire Central
Physical Condition - Cost
to Upgrade to Condition B
6 Facet information for ACH
£7,000,000.00
£6,000,000.00
£5,000,000.00
£4,000,000.00
£3,000,000.00
£2,000,000.00
£1,000,000.00
£0.00
Retained
Estate
Pavilion 5
Pavilion 2
Horsehoe
Building
Energy Performance Cost to Upgrade to
Current Standards 35-55
GJ per 100m³
Statutory Compliance Cost to Upgrade to
Condition B
DDA - Cost to Upgarde to
Condition B
If the programme does not proceed, capital investment of approximately
£19M will be needed to clear all the backlog maintenance and to bring the
accommodation on the Ayrshire Central site to an acceptable standard.
Ailsa campus
Whilst clinical care on the Ailsa campus is of the highest quality, further
mental health clinical development in South Ayrshire is currently constrained
by the limitations of the existing built environment, for example, the majority
of the buildings on the Ailsa Hospital campus where clinical care is provided
are ageing, functionally unsuitable and in poor physical condition.
Specifically, in the Board’s current 6 facet survey, Ailsa Hospital is listed as
Estate Code category C (below acceptable standards) for functional
suitability and category 3 (adequate) for space utilisation. Figure 8 shows
more information on the Ailsa 6 facet report.
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Figure 8: 6 Facet for Ailsa campus
Ailsa 6 Facet Information
Physical Condition - Cost to
Upgrade to Condition B
£60,000.00
Energy Performance - Cost
to Upgrade to Current
Standards 35-55 GJ per
100m³
£50,000.00
£40,000.00
£30,000.00
Statutory Compliance Cost to Upgrade to
Condition B
£20,000.00
£10,000.00
£0.00
Clonbeith & Iona, Lewis & Croy & Croy
Dunure
Jura
Day Hospital
DDA - Cost to Upgarde to
Condition B
Although there have been considerable attempts to ensure the interior
environment of the in-patient areas within the non-acute wards is of high
standard, there are increasing challenges with regard to providing modern
insulation, plumbing, drainage, heating and waste disposal.
All of these would be addressed by provision of purpose built, modern
accommodation.
Efficient and Sustainable Considerations Proposed
NHS Ayrshire & Arran will embrace and comply with the energy and carbon
reduction principles set out in the current edition of the Scottish NHS
Encode/DoH SHTM 07-02. It is however recognised that the units used for
benchmarking are changing to align with central government policy and
Technical Standards requirements, and that kWh and kG of carbon
emissions per metre squared, will replace benchmark references to
GJ/100m3. NHS Ayrshire & Arran will produce suitable Technical Reports to
illustrate and substantiate the appropriate design and energy management
decisions taken for the programme. In particular NHS Ayrshire & Arran is
investigating the use of renewable energy sources (solar thermal, solar
Photo Voltaic, biomass, ground source heating and cooling), and low carbon
solutions, including combined heat and power/tri-generation plant, heat
recovery techniques, and industry standard energy efficiency measures.
The current proposals will facilitate the application of an Environment
Management System. This is in accordance with the mandatory
requirements set out within the Environment Management Policy for NHS
Scotland (HDL (2006)21) and NHS Ayrshire & Arran’s own Environmental
Management Policy and Sustainable Development Statement. NHS Ayrshire
& Arran will also take cognisance of NHS Scotland’s Sustainable
Development Strategy document CEL 15 (2009).
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NHS Ayrshire & Arran will promote sustainable development and
demonstrate an integrated approach to the social, environmental and
economic factors including any local strategies supported by North Ayrshire
Council.
The facilities will deliver benefits to the environment, such as:
•
•
•
•
•
•
•
•
•
•
•
•
Demonstrate that climate change issues have been addressed through
the proposed design;
Demonstrate the use of recycled products within design specifications;
Provision of an energy efficient design that takes account of the need for
energy management and maintenance costs, and whole life cycle
needs;
Provide projections for energy performance and whole life cycle running
costs;
Propose innovative options delivering further efficiencies, highlighting
their benefits;
Produce good documentation, which clearly defines the design;
Produce robust risk management throughout the design, construction
and handover phases of the project that embrace the aims of the
Sustainable Development ethos;
Adopt hierarchical energy efficiency and waste management strategy –
reduce, re-use and recycle waste during construction and operation;
Implementation of an Environmental Management System (EMS /
Corporate Greencode) for accreditation with ISO 14001;
Contribute to minimising ozone depletion, global warming, air and water
pollution and non-renewable resource depletion;
Respect the local landscape and protect natural habitat and species
taking due account of the UK Biodiversity Action Plan and the Nature
Conservation (Scotland) Act 2004;
Avoid sources of ionising and electromagnetic radiation and any design
features associated with sick building syndrome;
•
Maximise efficient and effective removal and transportation of all forms
of waste;
•
Advise NHS A&A in adopting maintenance regimes which maintain
optimum performance;
Avoid the use of harmful building products and processes; and
•
• Maximise natural daylight, natural ventilation and passive solar energy;
Through these measures we aspire to achive a BREEAM “Excellent” rating.
(currently assessed as 70.3%)
In addition NHS Ayrshire & Arran will explore the use of prefabricated
elements to achieve good quality control, ease and speed of installation and
flexibility for future use.
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The design of the new development will promote NHS Ayrshire & Arran’s
commitment to providing a sustainable estate that meets the needs of the
present without compromising the ability of future generations to meet their
needs in all of its activities.
Sustainability will be further discussed and articulated in Section 2 Sustainability.
Equitable Issues Current
Transport
NHS Ayrshire & Arran is committed to addressing transport and access
planning in line with national, regional and local transport policies and
planning controls which require the need to offer realistic alternatives to the
use of the private car for some journeys.
Ayrshire Central Hospital is located within North Ayrshire at the northern end
of Irvine, approximately two miles from Irvine town centre adjacent to the
A737 Kilwinning Road which is the main north-south arterial route between
Irvine town centre and the A78. Ayrshire Central Hospital can be accessed
in a number of ways depending on how far patients, visitors and staff have
to travel, this section details ways to access the site.
Pedestrian Access
Ayrshire Central Hospital site is a large site which is presently not conducive
to walking within the site due to varying standards of walking paths provided.
Pedestrian access within Ayrshire Central Hospital grounds is of varying
standards. Some areas of the site particularly at the South end of the site
have little or no pedestrian footways leading to the buildings with
pedestrians required to walk along the roadways to door entrances.
Figure 9 shows the 1600m walking catchment area for acceptable travel
distances to services and facilities from Ayrshire Central Hospital.
Cycle access
On road and off road cycle path/lane provision to Ayrshire Central Hospital
and within its grounds is poor. Figure 9 shows the 2500m cycling catchment
area for acceptable cycle travel distances to services and facilities from
Ayrshire Central Hospital.
There are no cycle lanes along the A737 and no road cycle lane provision
between Irvine Town Centre and Ayrshire Central Hospital. Access can be
obtained via the National Cycle Network Route 7/73 approximately 1km from
the hospital as illustrated in the map provide by North Ayrshire Council, (see
Figure 9). No marked cycle lanes are provided within the main access to the
hospital.
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Public transport information
Public transport information including bus and rail timetables is available at
Ayrshire Central Hospital from the following reception areas:
• Mammography unit
• Outpatients/x-ray
• Central administration building (horseshoe)
An Infopoint telephone travel and information help point is located within the
hospital at the outpatients/x-ray entrance area providing free phone access
to travel line and the local taxi company.
Vehicular access and current traffic flows
There are two main entrance access points for Ayrshire Central Hospital
from the A737 Kilmarnock Road serving the north and south sides of the
hospital site. The hospital site access roads are 7.2m wide and have ‘STOP’
signs and markings for exiting traffic.
An additional road access to the hospital site is available via the narrow
gated access from Castlepark Road at the south end of the hospital site.
This entrance is approximately 100m along Castlepark Road, east of
Kilwinning Road. This access road is available for general access but is
mainly used by staff.
Parking
Ayrshire Central Hospital currently has 430 parking spaces this will increase
to 630 in the new development including an appropriate number of parent
and child and disabled parking places.
The current total of 430 car parking spaces is broken down as follows:
Total Car parking spaces: 430
Marked Car Parking Spaces: 380
Disabled Car parking Spaces: 50
% of disabled spaces: 11.63%
Car parking within the hospital is uncontrolled and operates on a first come
first served basis with no restrictions on duration of stay. Parking is also
evident outwith defined parking bays, designated car park areas, on yellow
lined areas and within restricted areas around the site. The hospital site
currently has no legal status with associated Traffic Regulation Order to
enforced parking restrictions on yellow lines.
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Equitable Considerations Proposed
Transport
Vehicular access and circulation will be from controlled junctions on the
A737 Kilwinning to Irvine Road. The aim is to separate delivery vehicles
and other vehicles as early as possible on entering the site and options will
be considered for a separate service road potentially using the existing
access to the hospital.
It is intended that the existing perimeter drive is retained and becomes part
of the circulation system but the aim is to separate and minimise conflict
where possible between staff, visitor, delivery and FM vehicles as they
enter, move around the site and access the building.
The main entrance hub to the new hospital will be highlighted with a shared
plaza and would allow for bus access and include turning circles and
designated drop off place only.
Emergency vehicles and visitors setting down patients/ staff and disabled
access and car parking would be able to access the Plaza. Staff and
visitors arriving by car will be directed to a distributor road linking all car
parks.
Pedestrian and Cycle Access
The aim is to segregate where possible pedestrian access and circulation
including cyclists from vehicular movement.
Shared Pedestrian/ cycle paths entering the site from the A737 to either side
of the Main Entrance Drive.
Pedestrian paths within car parks orientated in a north/ south alignment feed
into east/ west distributor paths.
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Figure 9: Ayrshire Central Hospital catchment area
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An entrance plaza is proposed at the hub as an entrance to the new hospital
and will provide a welcoming arrival experience. The entrance area would
consist predominantly of hard landscaping and include signage, street
furniture and lighting. The aim will also to be to avoid cluttering the entrance
area
Parking
Under the current proposals car parking provision will reflect the guidance
stated within SHTM 07-03, which will result in an overall increase of 200 car
parking spaces i.e. from 430 to 630. A suitable car parking management
strategy that reflects NHS Ayrshire & Arran’s policies on transport will be
implemented before the new facility is operational.
A hierarchy of landscape treatments will be introduced to structure parking
and movement zones. Structure landscaping will be introduced to
compartmentalise the new development and screen the areas of car
parking. Tree avenues and tree rows would assist in identifying pedestrian
circulation routes to the Main Entrance from the Car Parks. Where there is
insufficient space to introduce trees, hedge lines will be used.
Timely Issues Current
Acute mental health and IPCU is currently located on the Ailsa campus,
which is a large disparate site. Transfer of patients is neither timely nor
dignified at the moment due to the disparate nature of the Ailsa Campus. In
addition those patients being transferred from 1D/1E at Crosshouse Hospital
are required to undertake a 19 mile ambulance journey with the associated
risks for patients and staff.
Within the current estate accommodation constraints mean there is little
opportunity to cater for specific diagnosis or presentation in any area with
associated impact on most efficient care delivery and patient experience
leading to longer episodes of care than may be achievable. Often admitting
patients to wards that have concerns regarding anti-ligature provision and
the ability to observe ‘at risk’ patient’s leads to delays in admission as
additional staffing is required. This in turn often leads to individuals having
to remain in the acute care setting for longer periods or requiring to be
transferred to the Acute Admissions or IPCU setting if their presentation is
no longer felt manageable within the non-acute setting.
Constraints regarding gender and presentation mix can lead to delays in
accepting individuals for transfer also until the ‘right bed’ becomes available.
Flexible, condition appropriate accommodation will address both these
issues and optimise the ability to respond to referrals on a timely basis and
increase access to this service.
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Timely Considerations Proposed
Acute Admissions/IPCU
The co-location of the new adult acute admissions service and IPCU will
mean there is ready access to each other’s service and reduce the time it
takes to effect a transfer.
The new build IPCU will be design specifically for the purpose it was meant
to serve and in doing so will address the issue of patient transfer. It will be
co-located with the adult acute admission wards and will therefore allow
discrete access.
The proposed model for the new-build non-acute accommodation is to have
a 30 bedded ‘Slow Stream Rehabilitation Unit’ provided on a single en-suite
room basis. The Unit would be sub-divided into smaller ‘pods’ that would
allow gender and condition specific adaptation to ensure the provision of
individualised person-centred care.
The ‘Fast Track’ Rehabilitation Unit will have 12 beds, again all single and
en-suite but 3 of these beds will be within single self-contained bed-sit type
accommodation to allow individuals to practice independent living skills prior
to discharge.
Both these rehabilitation wards will be purpose built and will address all of
the issues regarding observation and timely admissions.
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