An estimated 25% of blood tests are unnecessary with an annual cost to the trust of approx. £26.5 million. Aside from the huge financial impact, patients are undergoing unnecessary invasive procedures with detrimental impact on lab flow processes and inappropriate use of Doctor and Nursing Staff time. Some young people have multiple admissions to Beechcroft in a short space of time or bloods checked in A + E prior to transfer are missed and replicated. Longstanding use of blood template terms “Admission bloods” or “Eating Disorder Bloods” has added to the problem. Initial scoping exercise found one young person had 40 blood tests during their admission. AIM STATEMENT: Reduce baseline blood testing of Glucose, Lipids and TFTs by 10% by June 2021

QI project commenced December 2019 using the IHI Model for Improvement Methodology was promoted by the project team through conversations with staff, unit meetings, email and posters.

Outcome Measure: Total glucose, lipid and TFT blood tests recorded fortnightly for the unit over 18 months

Process Measures: Training as part of new nursing staff induction, reminders in daily nursing handover, number of staff attending Biochemistry liaison meetings

Balance Measures: Reduced blood test costs, reduced unnecessary staff workload

Change Ideas

6 PDSA cycles were implemented

• • Separate Bloods Diary for each ward – January 2020

• • Blood diary brought into weekly care planning meetings – July 2020

• • Education Posters displayed in ward clinical rooms – September 2020

• • MDT meeting with Clinical Biochemistry – April 2021

• • Junior Doctor to update bloods diary post weekly care-planning – May 2021

• • Bloods diary brought to daily nursing handover & dissemination of new monitoring guidelines – June 2021

Glucose tests reduced by 68% with new median of 2.2 instead of 7. Lipids and TFTs median of 10 remains unchanged.

COVID-19 has disrupted monitoring. Fundamental changes made within our service by stopping blood glucose monitoring and using BMs instead has led to significant improvements. We will continue to monitor results following 2 recent change ideas. We hope to include patient feedback moving forward.

To improve the information exchange between oncall junior doctors and ward teams between shifts including outstanding tasks, alerts and prompts to update clinical record systems accordingly (Rio). We aimed for the handover to be circulated to the correct recipients in 95% of cases as well as to improve its content. This would minimise loss of information and improve patient safety.

Handover document set up on MS Teams which is accessed by oncall junior doctors and day teams and can be updated live. Relevant training was offered to trainees during induction. We measured the number of days the document is updated and distributed and also measured the tasks not completed or not documented. We measured doctors' satisfaction via a survey.

We found that on average the handover document is updated and circulated correctly at a rate of 94.8% since the new MS Teams system was implemented. Participating doctors' survey showed that they felt that this system is safe and easy to use as well as reliable and more efficient than the previous system. They also noted that the training they received during induction was helpful and sufficient.

The digitalisation of the handover process using MS Teams, developed and improved through various PDSA cycles, has resulted in a system which the users find efficient, safe and easy to use. This leads to minimisation of information losses and improves patients' safety.

As a mental health team for homeless people, we are aware of poor health outcomes for our patients. They face the double-hit of chronic serious mental illness (SMI) and homelessness, reducing life expectancy. As outlined in guidance, “secondary care team should maintain… monitoring service user's physical health”. We aimed to improve recorded annual physical health checks according to Trust Key Performance Indicators (KPI) for weight; hypertension; diabetes; cholesterol; and screening for smoking, drugs and alcohol on SystmOne (e-patient record) in Westminster's Joint Homelessness Team's (JHT) caseload, with target of 90% by December 2021 set by Central and North West London (CNWL) NHS Trust.

Using monthly physical health KPI reports to target uncompleted annual health checks for JHT's 135 patients. PDSA cycles were used over a six-month period from July 2021 – January 2022.

Intervention 1: Using available GP data to pull across into our records, making use of existing information.

Intervention 2: Dedicated clinical session from FY2 doctor to assess patients with missing physical health checks.

Intervention 3: Specific teaching to whole MDT to increase awareness and uptake.

Intervention 4: Designed our own reporting to give real-time rather than monthly reporting.

Outcomes were measured from monthly Physical Health reports for the active caseload.

At baseline only 26.67% of patients had completed recorded health checks. Intervention 1 more than doubled our recordings to 54.17% over a 2-month period. Our second intervention further improved recorded physical health checks.

The third intervention increased our recorded physical health checks to 82.35% over a 2-month period. Notably, at the beginning of our project 7 out of 135 patients, had no engagement in physical health check monitoring, this reduced to 1 after intervention 3.

At the end of our fourth cycle, we had increased our recorded physical health checks to 83.93%.

Overall, results show an improvement of 57.26%, or a relative increase of 3.15 times the amount of recorded physical health checks over 6 months.

As a result of incorporating dedicated clinical time, teaching and real-time use of data, we have improved our recorded physical health checks. There is room for improvement with 16% of patients still with incomplete health checks and approximately 10% of patients without blood tests. Some of this is due to accessibility and engagement difficulties for people with SMI and entrenched rough-sleeping, with ongoing work being done.

To assess the job and training satisfaction of junior doctors working in Mental Health placements in Derbyshire; to highlight areas of good practice and identify areas that need improvement to enhance their working experience.

This is an ongoing Cycle of Quality Improvement to address Juniors Doctors enjoyment of work and job satisfaction. On a 25 point questionnaire we sought feedback as open response, graded response and free text. Questions were formulated using suggestions from Royal College of Psychiatrists Supported and Valued Review and BMA Fatigue and Facilities Charter. Advised areas of improvement from the previous 2017 Quality Improvement project were also reviewed and incorporated into the questionnaire design.

All junior trainees (including Core Psychiatry trainees, Foundation trainees, GP trainees and junior trust grade doctors) working between December 2020 to April 2021 in Derbyshire Healthcare NHS Foundation Trust were sent the questionnaire.

Official end of placement feedback from January-December 2020 was also compared to our findings.

15 doctors completed the questionnaire.

Areas of trainee-reported satisfaction included training on management of common psychiatric conditions (73%), weekly teaching sessions (100%), ability to organise leave (100%).

Areas of dissatisfaction included training on management of psychiatric emergencies (40%), poor regularity of supervision (53%), inadequate access to phlebotomy services (66%), ability to take adequate breaks (66%) and ability to fulfil training requirements (40%).

Discrepancies were noted in responses to similar questions in our questionnaire compared to the official end of placement feedback, with greater trainees answering with negative responses in this project.

This project highlighted areas of high satisfaction for trainees and showed specific areas for improvement. Trainees responses have been reviewed with Educators and Trust Management for collaborative solutions, pilot schemes and future QI projects identified.

Observer bias was noted, with greater numbers of doctors answering similar questions negatively when feedback was anonymous, suggesting that they may be giving more honest answers when their identity is concealed.

Despite the challenges posed by the pandemic, several resourceful initiatives were implemented, across the educational landscape. As the lead organiser of the academic forum the expectation was to develop a format for on-line monthly academic teachings with streamlining further innovative ideas of change to best effect. The key objective of this QIP,is to use virtual platform to establish an educational forum that is efficient, safe, reliable, easy to use and replicable

• • A zoom based online forum was convened using QI framework to identify gaps in the programme along with new ideas of change.

• • The attendees experience new innovative practices within the programme format, in line with the original NWLD forum programme.

• • A ‘think-group’ consisting of the previous NWLD forum lead, ID training programme director and higher trainee facilitators proposed ideas towards a varied educational topic bank, in line with the ID curriculum

• • Qualitative feedback from the forum members collected at baseline and regular intervals.

• • As part of the implementation of these actions, conducted workshops evaluating the impact of COVID-19 on Educational, Psychological and Clinical landscape

• • There were 18 virtual sessions,5 CPD hours per session, conducted monthly.

• • 9 sessions in the first PDSA cycle from June 2020 - Feb 2021, and 9 sessions in the second PDSA from March 2021-November 2021.

• • Impact of COVID-19 workshops & Complex case management workshops conducted in the first and second PDSA cycle as part of the monthly academic programme.

• • Participants for the academic regional teaching included Consultant Psychiatrist, higher trainees, Core trainees, Foundation doctor, specialty doctors, Medical Students and MDT professionals.

• • New members regionally, nationally and internationally became part of the academic programme both as attendees and as speakers along with the Chair of the ID Faculty.

• • The academic programme helped with educational and training needs. It helped in improving social participation for our members during COVID-19 pandemic.

• • Qualitative feedback has been collated and analysed. The feedback contains a wealth of comprehensive information that has been used to enhance the programme and training needs for the trainees and trainers.

• • The program is well-received and led to knowledge, skill, and attitude improvements.

• • The depth analysis of the feedback has facilitated a targeted approach that has brought a meaningful improvement, in the quality of training and education.

• • Audience participation and engagement remains a key area for improvement.

This QIP aims to improve communication and information sharing between the community LD team, administration team, service providers and wider stakeholders, to ensure patient safety. The primary objective is to evaluate local initiatives to improve communication between MDT professionals and wider stakeholders. The secondary objective is to improve patient safety and staff satisfaction.

The COVID-19 pandemic created unprecedented communication challenges within the workforce and highlighted areas requiring review; this included information sharing among internal and external teams, collaborative teamworking, support in absence of senior clinical leadership and transition pathways from Child and Adolescent Mental Health Services to adult LD services. The QIP was initiated in March 2021.

The discovery process included an initial consultation exploring practitioners’ experiences, areas for development and to share ideas for good practice.

We used QI methodology, following ‘plan-do-study-action’ cycles, to analyse change. Change ideas included a single point of contact for internal and external queries, regular complex case management meetings, development of a referral process and clinical review for complex cases along with teaching sessions.

Qualitative feedback from the team pre- and post-intervention, at baseline and regular follow-up intervals, in the form of monthly team meetings, emails, focus-groups and semi-structured interviews.

A full thematic map was created after initial consultation; themes included communication improvement between teams and external agencies, timely support for complex case management, improving transition processes and development of robust clinical review processes.

Qualitative feedback has been collated, analysed and final recommendations to be shared with the MDT professionals

Preliminary results have shown improvements in communication among the MDT, stakeholders, and external agencies.

The consultation process highlighted that there is a substantial need for standardisation and consistency within communicative practices to promote enhanced care delivery and improved patient outcomes.

Whilst there is always more to learn within any speciality, the particular zone of development for senior trainees and early career consultants is the management of the complex case. The factors underpinning complexity are varied, and can range from aspects of the service user such as complexity and severity of disorder and/or multi-morbidity, to aspects of their local social networks, to complexities arising from the service or care environment. The aim of this workshop was to offer a safe space for senior trainees and early career consultants to work through some principles that might be helpful, particularly where things seem to be getting into a pickle.

• • A 60-minute slot was proposed, as part of the Northwest Learning disability academic teaching forum.

• • The structure of the workshop borrowed the informality and spirit of support from Balint groups.

• • Attendees were prepared to talk about one of their cases anonymously, and why they might be getting into a pickle.

• • Soundings were taken and a particular case chosen to workshop in more detail, as an exemplar for others.

• • Each session focused on one or two themes from the wider set of themes suggested by the CCaRM framework (Spurrell, Potts & Shaw, 2019) currently being used by Greater Manchester and Lancashire SST to expedite their work.

• • Each session concluded with an evaluation discussion of workshop usefulness.

• • There were 6 virtual workshops in first PDSA cycle (June 2021-Nov 2021)

• • Each workshop lasted approximately 100–120 minutes, with 8–12 people attended in each session.

• • The intention for the workshop was to include senior trainees and early career consultants who are within the NWLD forum however junior trainees, senior consultants and other MDT professional also became part of the sessions.

• • Each session concluded with an evaluation discussion of workshop usefulness

• • Qualitative feedback has been collated and analysed from the evaluation discussion.

• • The information derived from the qualitative analysis indicates that there is a substantial need for regular complex case discussions for the purposes of enhanced care delivery and improved patient outcomes

This approach helped in enhancing the understanding of the case management for people with intellectual disabilities among forum members

We consider that the online workshops is a success and are planning further-PDSA 2 in order to create competent and well-rounded ID psychiatrist in the future in Northwest region.

The aim of the audit was to review the follow-up of new SSRI prescriptions for anxiety and depression in a primary care setting and to evaluate this against relevant guidance, including that provided by NICE. NICE guidelines recommend initial follow-up for patients newly prescribed SSRIs for depression at either 1 week or 2 weeks dependent on patients age and the perceived risk of suicide or self-harm.

An audit was carried out of new SSRI prescriptions and subsequent follow-up for 52 patients in a primary care practice in North Derbyshire covering the period January to August/September 2021.

The audit used patient notes which were manually reviewed to assess the initial consultation, prescription, documented suicide/self-harm risk assessment and follow-up plans. The length to initial follow-up and the number of subsequent follow-up appointments were also assessed.

The audit found that the median time to initial follow-up was 14.5 days for patients aged 18–30 years with only 12% compliant with the NICE recommendation of 1 week to follow-up. The median time to initial follow-up was 17.5 days for patients aged >30 years with only 19% compliant with the NICE recommendation of 2 weeks to follow-up. There were no significant differences in follow-up between males and females. 96% and 77% of initial consultations included a documented suicide risk assessment for patients aged 18–30 years and >30 years respectively. 88% of the new SSRI prescriptions were for sertraline 50 mg.

The above findings were presented to the clinical team at the primary care practice meeting with reminders of the NICE recommendations for follow-up and how these vary between different patient groups. The practice will carry out a repeat audit in 12 months.

Good medical practice encompasses teaching students which is a core competency for trainee doctors. The aim of this project was to assess and improve junior doctor participation in undergraduate psychiatry teaching.

2 surveys were conducted: 1) Psychiatry-related trainee doctors working in Severn Deanery were emailed a questionnaire to assess their involvement in undergraduate teaching, including barriers and motivators for teaching; 2) doctors with a formal role in teaching were sent a questionnaire to explore their views on recruiting trainee doctors to teach. Questionnaires consisted of multiple answer questions, matrix questions and qualitative free text answer questions. Trainees were then delivered a presentation advertising teaching opportunities. The impact of this on recruitment into psychiatry undergraduate teaching was reassessed by questionnaire.

44 responses were received to the first survey; 13 to the second. The most common answer trainees gave for factors that prevented involvement with teaching students was “unaware of teaching opportunities,” and “lack of overall availability due to clinical commitments.” The most common factor chosen as a motivator for involvement was “notification of session date/timing early in placement” and “protected teaching time in job-plan.” The results highlighted difficulties recruiting trainee doctors to teach, resulting in tutors reducing, cancelling or adapting sessions due to lack of support.

This project identifies barriers and motivators of trainee doctor involvement in undergraduate medical education. To ensure lasting participation of trainees in medical education, support is needed for protected time to teach in clinical roles.

Developing a mental illness and being commenced on psychotropic medication are factors that may interfere with the ability of an individual to drive safely as both can impact information processing, psychomotor actions and social interpretation. The Driver and Vehicle Licensing Agency (DVLA) suggests that certain medical conditions require driving licence holders to notify them for further assessment of their ability to drive. DVLA notifiable mental disorders include psychosis, schizophrenia, bipolar disorder, dementia and personality disorders. The doctor's legal duty is to assess the patient for any relevant diagnosis, inform the patient of their duty to report their medical condition to the DVLA and for the doctor to comply with the legal duty to inform the DVLA of any patient who won't or can't notify the DVLA of their medical condition. The authors conducted a quality improvement project to evaluate and improve the number of fitness to drive assessments completed for patients admitted to the five wards (three general adult, one older adult and the Psychiatric Intensive Care Unit) at Clock View Hospital.

The electronic (RiO) record for each inpatient on the five wards was scrutinised for: whether the patient's driving status was established on admission; whether the patient was notified of the DVLA rules if they did drive; whether the patient agreed to fulfil their duty of notification and, in instances where they were not, whether the medical professional had taken appropriate steps to address this.

74 patients on the five wards were included in the sample. Only nine of the 74 patients had driving status documented on admission. Three of these nine patients were noted to be driving or learning to drive and were not notified of the DVLA rules. Four of the nine patients were no longer driving and so discussion about DVLA guidance was unnecessary. The remaining two patients were confirmed to be driving and informed of the DVLA regulations. Both patients agreed to comply and therefore no further action was indicated.

A review of current practice indicates a deficit in incorporating driving status and fitness to drive assessment into the clerking proforma following admission to Clock View Hospital. The second half of this cycle will implement change and raise awareness amongst inpatient medical and nursing staff of the need to consider this important issue prior to discharge. A re-assessment of the effectiveness of these changes will be carried out in the future.

Patients often have negative experiences of police in their daily lives. Police involvement in mental health services can make an encounter feel disciplinary rather than therapeutic and exacerbate mental distress. People with mental illness, especially of minoritised backgrounds, are more likely to die after police contact, than other groups. Our aims were to: 1) explore patient experiences of being admitted onto the ward under section via the police, 2) explore patient understanding of the role the police play in mental health services 3) Use experiential data towards introducing trauma informed care in an inpatient setting

A clinician administered questionnaire was conducted on an acute male inpatient ward, with 12 consenting male inpatient participants. All were involuntarily detained, ranging in age from 22 to 56 years; 11 out of 12 were of an ethnic minority background.

The questionnaire consisted of a mixture of open-ended questions and closed Likert scale questions with answers ranging from “strongly agree” to “strongly disagree”. Questions covered themes relating to the experience of admission and the ward environment, personal and communal experiences of policing, views on the role of policing in mental health service provision. Data were collated and presented in a local QIP showcase.

A significant split was identified between answers to open-ended and closed questions. When offering Likert based responses, 66% of participants felt safe with the police and believed that the police had a role in keeping people with mental health problems safe; 50% felt the police role should be greater in the future.

When responding to discussion-based questions, participants were critical of policing in relation to managing mental crises. Participants offered elucidative answers covering themes ranging from feeling a lack of agency, and the traumatic nature of criminalising mental distress, to concerns about abuse of power, the desire to limit the policing role to criminality and lack of trust engendered from experiences of racial injustice.

Our results demonstrate that patient views on policing roles in mental health service provision are complex. The experiences of involuntary admission through the police are often traumatic, rooted in past police involvement in patient's lives. Although it is acknowledged that at times no feasible alternative is available in hostile situations, this QIP opened an important, previously avoided, discussion. This will hopefully lead to introduction of more trauma informed care in an inpatient setting.

Northern Ireland has had the highest suicide and self-harm rate in the UK since 2012 according to National Statistics Office with 12.5 deaths per 100,000 population compared to 10.5 in the rest of the country. Evidence shows that the risk of suicide hugely increases following self-harm, and the greatest risk is immediately after the self-harm episode. Better access to health care, especially to primary care, in this period, can actively reduce the risk to this vulnerable patient group. Patients assessed for self-harm in the emergency department are often followed up by the mental health/crisis team. Due to lack of resources and staff shortages this is often not possible in a timely fashion. NICE suggests that patients should be offered a follow-up appointment in primary care within 48 hours of discharge. We aimed to ensure 70% of patients discharged from secondary care following an episode of suicidal ideation or self-harm are contacted proactively by mental health practitioner (MHP) or GP within 48 hours of communication from secondary care.

The project underwent two PDSA cycles. An electronic workflow was created to provide easy patient identification, assessment and follow-up. A process mapping was done after discussion with the GPs, administrative team, practice nurses and MHP. Outcome was measured by finding out percentage of patients: 1) Contacted within 48 hours of communication following an episode of self-harm 2) Appropriately coded 3) Comprehensively assessed 4) Risk stratified and minimized following each cycle.

Over a period of three months, following two PDSA cycles, the frequency of these contacts increased from 0 to 80% (median) with an average 3.8 (83%) patients reviewed per week. The patient experience and satisfaction also improved significantly.

General practice (GP) has long been known as the next of kin for patients in the health care system. As GP is mostly the first point of contact for the patients, it can contribute significantly to ease the rising pressure on the mental health team. Also, a small number of weekly contacts from each GP can make a huge difference in nationwide patient safety and experience. We hope this intervention will significantly improve patient safety and reduce further self-harm presentation to ED in the long run.

The Enhanced Trauma Pathway (ETP) at Berkshire Healthcare NHS Foundation Trust was established in 2018 to manage high demand on a highly specialist psychology team called the Berkshire Traumatic Stress Service (BTSS). The ETP is used to treat complicated cases of Post-Traumatic Stress Disorder (PTSD) within the IAPT service. However, because of the ETP there is now a cohort of Service Users (SUs) presenting to IAPT with a higher complexity than has been typical, presenting new challenges for the service. We aim to evaluate and redesign the ETP within IAPT to meet the needs of the changing population.

Clinically Led workforcE and Activity Redesign (CLEAR) is a workforce transformation methodology with four unique stages: i) Clinical Engagement: in-depth qualitative analysis of interview data from staff ii) Data Interrogation: cohort analysis using clinical and workforce data visualisations and analysis, iii) Innovation: developing novel solutions with insights from triangulated qualitative and quantitative data, iv) Recommendations: formulation of new models of care (NMOC) and smaller quick high impact service innovations. Thematic analysis was used for the qualitative data. Quantitative data analysis was conducted using the IAPT dataset.

27 semi-structured interviews were conducted with staff. SUs on the ETP had longer waiting times, their treatment took longer (18 sessions for ETP Vs 12 for core step 3) and they had lower recovery rates: 32.9% for ETP, 49.9% for core step 3 in IAPT and 57.3% for the whole IAPT service. SUs on the ETP presented with increased risk concerns, often not mitigated by stabilisation work offered. Thematic analysis also identified challenges with recruitment, a lack of qualified staff and inefficient use of skills across the pathway. Staff well-being was found to be paramount, however supporting staff was found to be challenging due to national constraints placed upon IAPT and the targets the service is asked to achieve. A series of recommendations were made including three options for a NMOC. The options suggested different ways to redesign the pathway including an option where there would be a trauma only team within IAPT working exclusively on the ETP.

This evaluation highlights the challenges for the ETP and identifies NMOC to reduce their impact on the service. Further work is required to assess the NMOC once it has been implemented and to further evaluate the needs of the SUs presenting to this service.

Forensic service-users (SU) are often transferred between units at short notice, with little information about their new ward and unaddressed concerns. The findings of our first Plan, Do, Study, Act (PDSA) quality improvement project exploring SU's transfer experiences from medium to low secure units during COVID-19 in East London. Whilst unsettling, it may also impact therapeutic progress due to difficulties in developing new relationships with clinicians and ward residents. Our second PDSA cycle explores SU concerns and identifies improvement recommendations.

Five SUs consented to take part in the experience-based co-design approach. Remote semi-structured interviews explored experiences and suggestions for improvement. Audio transcriptions were thematically analysed to assess information provision, transfer expectations, new ward perceptions, available support and overall reflections.

Recipients of a tour prior to moving felt most informed about the transfer and reported not requiring further information. Without the tour, some SUs were unaware of the name or type of their future ward. Therefore, SUs recommended everyone should have a tour prior to transfer, or where not possible a video tour. Two weeks was felt to be the ideal amount of notice prior to transfer and in the absence of this, weekly updates during ward round. Being able to talk to an SU who had recently moved to the new unit would be ideal, or in lieu of this a pre-recorded question and answer (Q&A) video.

SUs were interested in the new ward policy regarding leave and mobile phone criteria. A recurring issue involved SUs being promised unescorted leave on the new ward, but this not taking place. Importance was also placed on the family being updated during the transfer and moving with a preferred staff member. Many SUs felt the process was smooth yet held concerns about forming new friendships. They felt their psychologist, primary nurse or ward manager were easiest to approach with concerns. On the transfer day, SUs benefitted from the encouragement and congratulations from the old team, however cited feeling rushed when moving.

Implementing a pre-recorded tour with unit facility highlights and a recent SU transfer Q&A video would improve the transfer experience. Having clear policies regarding leave and mobile phone criteria prior to moving improves clarity. Our approach to include SUs in the transfer meeting with both the new and old wards ensures transparent expectations. We continue to monitor the success of these interventions on transfer experience through further PDSA cycles.

The Tony Hillis Unit (THU) is a locked rehabilitation unit for men aged 18–65 years with Treatment Resistant Psychosis, with or without mild personality disorders; drug and alcohol misuse; and challenging behaviour. The multi-disciplinary team including psychiatrists, psychologists, nurses, occupational therapists and specialist pharmacists offer service-users a holistic, personalised and pragmatic management plan to facilitate an improvement in their level of functioning. This service evaluation aimed to review the effectiveness of our intervention as a unit as defined by functional outcome at six months pre- and post- admission.

A retrospective, mirror-image study design was used to collect data. Data were obtained from South London & Maudsley's Electronic Patient Journey System (ePJS) records. All patients discharged from THU over a two-year period, from May 2019 to May 2021, were considered in the study (n = 25 patients). Two service users died during the evaluation period and were excluded. A further service user was excluded as he had an admission length less than 28 days. Variables recorded included patient demographics and the presence of biopsychosocial interventions at THU including Clozapine initiation, engagement in weekly 1:1 occupational therapy (OT) and 1:1 psychology sessions. The functional status at six months pre-admission and post-discharge was defined by placement type, graded in terms of level of support; 1 = Psychiatric Intensive Care Unit, 2 = Acute ward, 3 = Rehabilitation service/Prison, 4 = Care home, 5 = Supported accommodation and 6 = Independent living. The change in patient acuity pre- and post- THU was compared using Wilcoxon-signed rank test.

23 service users were included in this evaluation. The average admission length was 365 days, and average age at admission was 38 years. The difference in patient acuity before and after THU intervention was statistically significant (P < 0.005), with an overall reduction in level of placement support required. The most common placement prior to admission was an acute ward, compared to a rehabilitation service six months after discharge. 60% of patients (n = 13) were newly initiated or re-titrated on Clozapine during their admission, with a further 4 patients already on Clozapine. 82% of patients engaged with 1:1 weekly OT and 72% engaged with 1:1 weekly psychology sessions.

This study demonstrates the effectiveness of our role as a locked rehabilitation unit. It outlines some of the key biopsychosocial interventions likely contributing to this, including initiation of Clozapine.

There is a well-known bidirectional relationship between mental and physical health. A thorough mental and physical health assessment of new inpatients on admission is crucial to assess possible organic causes of psychiatric presentations and enable appropriate treatment to be commenced in a timely manner. We noted a pattern of incomplete clerking, leading to delays in commencing treatment and increased workload pressure on the ward medical team. Our audit aims to assess how thoroughly and in what time frame patients' admission assessments are being completed on an acute psychiatric inpatient unit.

A sample of 20 patients was used for each cycle. Eight components were identified from the Trust clerking procedure. These were a full psychiatric history, capacity assessment, prescription chart, physical health systems review, physical examination, blood tests, ECG and VTE assessment. The expected standard was completion of all of the above at the point of admission or, if applicable, adequate documentation of patient refusal with documented reattempt within 24 hours.

Electronic patient records were retrospectively reviewed to identify whether each component was completed, the number of days from admission to completion and if completed by the clerking doctor. Evidence of documented patient refusals and the number of incomplete draft entries were noted.

Initial results showed only 20% of patients (n = 4) had the full expected clerking procedure completed at admission. Physical health assessments (ECG, blood test, physical examination) had the lowest completion rates. When components were not completed by the clerking doctor, there was often a delay of several days from admission to completion of by the ward day team. For 50% of patients, some assessments were never completed (without adequate refusal documented). Eight patients did not have a completed VTE assessment by the point of discharge.

Reasons were identified for the poor completion rates of clerking assessments. These included a lack of understanding by on-call doctors about the importance of completing all assessments, unfamiliarity with ward equipment, lack of adequate handover to the ward medical team and staffing pressures. A new handover checklist was introduced for clerking doctors to use and enable better communication with the ward team. Clerking procedure summaries were displayed in on-call rooms and additional teaching was organised.

People with mental health issues have challenges in accessing medical care and it is hypothesised that this may result in a significant number failing to receive protection from COVID -19 by means of vaccination. This study aimed to identify the number of inpatients on a psychiatric general ward (Meridian ward) between May 2021 and June 2021 who were fully vaccinated against COVID-19 so that unvaccinated patients could be offered vaccination during their inpatient stay.

Data were gathered on the COVID-19 vaccination status of all patients on Meridian ward (inpatient mental health ward) admitted between May and June 2021. This was a total of 10 patients. This information was gathered directly from the patients, their summary care records and GP records. We also audited whether the patient's vaccination status was recorded in the notes.

50% of the patients were fully vaccinated. 20% had received one vaccine and 30% of patients were unvaccinated. 20% of the unvaccinated patients received their first dose during admission.

Patients with mental health issues sufficient to result in psychiatric admission face additional challenges when it comes to receiving a COVID-19 vaccine. It is important that healthcare workers are aware of this and facilitate interventions that maximise vaccination in this at-risk group. To improve uptake among this group it is recommended:

• • Patients’ vaccination status is assessed and recorded during inpatient admissions.

• • GP surgeries should identify patients on their database with mental health issues who are unvaccinated and providing these individuals with support around accessing information, transport or providing vaccinations at patient's homes.

• • There should be clear documentation of vaccination status on summary care record and ward notes.

VTE-related deaths are a leading cause of preventable mortality amongst all hospital inpatients. Psychiatric inpatients are at greater risk of this, due to administration of antipsychotic medication and longer inpatient stay. This is particularly significant during the COVID-19 pandemic, not least as it is a disease known to cause hypercoagulability, but also due to an increase in mental illness and extended admission, resulting from an overwhelmingly run social service. The objective is to analyse VTE risk assessments performed for the 23 patients at Lambourn Grove, a continuing care unit for old age psychiatric inpatients, diagnosed with dementia. The aims are to assess; the frequency at which VTE risk assessments are performed, the accuracy of each assessment and the subsequent management and appropriateness of preventative measures taken.

A retrospective study was conducted of 23 service users. Data were collected from the VTE assessment form on the local electronic patient record system, and analysed to assess compliance with local guidance. GP records were consulted to cross check data and ensure accuracy of information inputted. Improvement measures include presenting at the local teaching session and implementing a mandatory monthly review onto the ward round proforma. A second cycle will be carried out to assess the success of these interventions in improving best medical practice.

Of the 23 service users, 20 patients had their VTE risk assessment completed on admission and there was a delay of over a month with the remaining 3 patients. Of significance is that of all initial VTEs, 6 out of 23 contained inaccurate details, such as omission of comorbidities or a subjective assessment of mobility, indicating the need to use a standardized tool which allows for comparison across time. The mean admission duration for all 23 inpatients, as of February 2022 was calculated to be 16.2 months, with a range of 2 and 59 months. 15 patients did not have their VTE risk assessment repeated during admission, and of these 2 did have a change in their risk profile, indicating non-adherence with NICE guidelines.

This study has identified significant areas for improvement, specifically the need for clear timing for repeated VTE assessments, consistent sources of patient's medical history and documentation of mobility status. The project has highlighted the need for a more robust VTE assessment protocol which is currently being developed, to improve patient mortality and outcomes.

We aim to explain more about PMDD in young people and explore the evidence looking at the role of CBT as an intervention. We aim to develop high-quality psychoeducation material with the involvement of young people, to be able to offer clinically relevant information and empower young people with PMDD.

A literature search was conducted in 2019 and updated in February 2022 using the Cochrane Library, Psych-info, MEDLINE, Cinahl, EMBASE and Google Scholar, to look at the evidence available for CBT in young people with PMDD or PMS. The search included PMS as well as PMDD due to the heterogeneity in definitions used in studies.

Focus groups with young people are underway to develop high quality written psychoeducation material about PMDD.

There were no specific studies looking at CBT as an intervention in young women under the age of 18 with PMS or PMDD. There was one intervention study with a treatment arm of psychoeducation in 62 young people under 18 with PMS versus a no treatment group (Taghizadeh 2013), with improvement in symptoms after 3 months from baseline reported.

There were more studies available in women over the age of 18. The search identified 3 meta- analyses in 2009 and 2012 (Busse 2009, Lusty, 2009; Kleinstauber 2012) and a more recent systematic review (Landolt 2020). Kleinsteiber et al included 22 RCTs, with a median age of 39, and broadly showed CBT to have a small to medium positive effect size, although any conclusions were limited due to the small numbers involved in the individual trials and methodological flaws. Landolt 2020 looked at CBT or elements of CBT as an intervention arm over the last 30 years or so in woman of all ages. Variations of CBT including virtual, group, couple and psychoeducation alone were included, and all were reported to have favourable outcomes.

There is a huge gap in research looking at PMDD in the adolescent population. Translating research from adults is not ideal. Increasing awareness and developing psychoeducation is a step in the right direction.

It has been well publicised the pressures on inpatient bed capacity within mental health services in recent years. The RCPsych have stated in their publication ‘Exploring mental health inpatient capacity’ that bed occupancy has risen above their recommended 85% occupancy target in most areas. Waiting lists for beds have also grown. The aim of this project was to identify whether there could have been any extra community resources in place that could have prevented admissions to hospital within an older adult CMHT. This in turn reducing the demand on inpatient beds.

Inclusion criteria: All patients from the older adult CMHT admitted to either an organic or functional mental health inpatient bed between the 1st September and 31st December 2021.

All patients who met the inclusion criteria were discussed as part of a panel consisting of members of the MDT who were involved in the patients' ongoing care. The panel discussed each patient and individually scored each admission on a scale of 1–5 (where 1 was deemed to be very avoidable and 5 completely unavoidable). Where an admission did not score a 5 we considered whether anything could have been in place to have prevented the admission.

Our search identified 21 patients who had been admitted to the respective old age psychiatry ward during our period of interest. The predominant diagnosis of these patients was vascular dementia (n = 5), followed by Alzheimer's disease (n = 3). Following our consensus panel discussion, we identified that the most common reason for admission to hospital was for management of behavioural and psychological symptoms of dementia (n = 10), followed by increasing patient vulnerability (n = 4) in the community. Carer stress was a theme in 2 admissions. Following panel discussion regarding potential avoidability of admission, we identified that 14 out of the total of 21 admissions scored a 5, 1 scored 4, 1 scored 3, and 5 scored 2.

Behavioural and psychological symptoms of dementia continues to remain a significant clinical challenge and was the most common reason for admission in our patient cohort. The majority of admissions to hospital in our cohort were deemed unavoidable as a result. However, we identified that carer stress was a significant theme in 2 out of our 21 admissions, suggesting potential scope to implement services which may reduce carer stress and ultimately, prevent hospital admission.