The SPA service takes referrals from general practitioners (GPs), medical professionals, the London Ambulance service, the London Police, psychology and social services, and from patients themselves and their family members or support groups. Some of these referrals require input from secondary care, but others can be solved within primary care if given specialist advice, this minimizing the time spent by patients in the healthcare system and minimizing also the NHS costs.

Our aim was to evaluate the implementation of the Advice from Medics Service in a 1-year period.

We examined a random sample of 200 referrals between 1st of April 2019 and 31st of March 2020 out of all referrals that were considered, after the triage, to be appropriate for an advice on treatment provided by the medics as an alternative to a clinic appointment in secondary care. We collected information from the electronic patient records regarding the dates of referrals, the senders of referrals, the type of referrals, the age and gender of patients and the reasons to be referred, and finally we analysed the outcome of the referrals and compared it with the action requested.

Of the 200 referrals, 113 were for female patients and 87 for male patients. The age of patients was between 18 and 91 years old, with a median of 43 years old.

The person/authority making the referral was the GP in 179 cases, and others in 21 cases.

The referrers asked for review in 74 cases, urgent review in 2 cases, review and advice in 31 cases, only advice in 46 cases, and did not state the type of referral in 47 cases.

The primary pathology implied was affective in most of the cases (122), followed by psychotic (31) and neurotic (22), organic (8), of personality (5), hyperkinetic disorders (5), due to substance misuse (4), of psychological development (2) and learning disability (1).

The outcome of the referrals was as follows: 19 patients (9.5%) were seen by the Crisis Team, 11 (5.5%) were referred to other teams, 4 (2%) did not engage with SPA, and the rest of 166 (83%) referrals were solved with advice.

The outcome was extremely favourable as the majority of referrals requested medical review but most of them (83%) were solved with specialist advice to GPs or other professionals, highlighting that the implementation of the Advice from Medics Service has been an improvement to the SPA.

To establish a physical health clinic in a community CAMHS to monitor patients in the NDT who are on stimulant/antipsychotic medication

To re-audit to assess adherence to physical health monitoring in accordance with guidelines

Studies have indicated that people with severe mental illness have higher rates of mortality and are prone to development of physical health problems compared to the general population. Monitoring physical health is therefore important as it allows early detection and intervention where appropriate.

17 out of 120 patients in the NDT were identified as taking either an antipsychotic (8 patients) or stimulant medication (9 patients). Physical health data required were determined by local policy and the Maudsley guidelines.

Parents were invited to attend the clinic with their child through telephone calls. Height, weight, blood pressure and pulse were measured in the appointment. A blood test form was provided for parents to take to local outpatient phlebotomy services. A GP letter was sent with the results of the physical health check with a request to conduct an ECG and notify us of any abnormal results. Feedback forms were collected from parents to share their experience of attending the physical health clinic.

Five patients were identified as having difficulty attending the CAMHS clinic due to refusal/challenging behaviour. For three patients, school visits were organised to conduct a physical health check.

The results from the second round of the audit indicate an overall improvement in the adherence to monitoring guidelines for antipsychotic and stimulant medication. This was particularly evident for the patients on antipsychotic medication. Feedback collected from parents regarding the service provided was also positive.

The physical health clinic identified challenges preventing 100% compliance in all patients. This included difficulties with parents bringing their child to CAMHS due to challenging behaviour. In a few of the patients, it was possible to solve this issue by conducting a school visit.

It was also observed that there were multiple instances where challenging behaviour lead to inability to conduct certain tests including blood pressure, blood tests and ECG. Additional strategies should be considered to improve compliance.

A notable issue that also arose from the development of the physical health clinic was that it was unclear how to obtain an ECG at CAMHS.

Continuation of the clinic as well as extension to include patients within other teams at Tower Hamlets CAMHs would be recommended.

Prolonged waiting times for admission to psychiatric hospital settings are a common and widespread issue. Delayed admissions may result in poorer outcomes due to prolonged mental suffering and delays in initiating treatment. Long waiting times also have a negative impact at a service level, impeding patient flow.

National guidance has been recently updated, recommending that patient transfers to secure services take no longer than 28 days from referral. These transfers are frequently affected by delays in admission, possibly resulting in increased risk to patients, staff and the public.

The aim of this project was to audit all referrals to Broadmoor High Secure Hospital in England within a one year period with special focus taken on calculating the time taken from referral to admission. We aimed to assess if there were any rate limiting steps which could be targeted to reduce time from referral to admission.

We collected data and conducted a retrospective cohort review for all admissions from September 2019-September 2020. Where available, information was obtained for each step of the referrals process. Individual patient records were reviewed where required.

Exclusion criteria: data withdrawn, transfers from other high secure services (HSS), incomplete data, “MOJ instruction” or urgent admission bypassing the process.

18 cases were excluded as per exclusion criteria. 46 patients were included in the study. 16 referrals originated from medium secure psychiatric hospitals, and 30 from prison.

The average time from referral to admission was 44.3 days. Admission of patients from MSUs was quicker, taking an average of 40.3 days when compared to prison referrals, which took 45.9 days.

The breakdown of timings for each step in the referrals process was calculated to determine if a rate limiting step could be identified.On average it took 2.1 working days to allocate a case to a clinician, 7.6 days for an assessment, 9.2 days to complete a report and 3.5 days to submit this to the admissions panel. The mean time from referral to the date of the panel hearing was 22.5 working days, and admission took a further 21.8 days on average.

The current average time to admission exceeds the new 28 day recommendation. This could both be due to the COVID-19 pandemic, and miscommunication about time targets. We will review the process and aim to reduce the time from referral to admission in line with new guidance.

The following project explores where Wathwood Hospital stands in provision of services to its elderly patients.

The only dedicated forensic medium secure unit for elderly offenders in England is the St. Andrews medium secure unit in Northampton with only 17 beds. Due to the limited beds, other units must accommodate elderly patients, which raises the question whether these units can provide the appropriate services for this very vulnerable population.

Inclusion Criteria:

Male

>55 years of age

Admitted from 2012 onwards (from when database was maintained)

Data were gathered using patient electronic records including index offence, mental disorder, physical health comorbidities and discharge destinations. Patient identifiable data were anonymized to protect their identities.

A staff survey was also conducted to find their perspective on managing elderly patients and whether Wathwood Hospital had the appropriate resources for elderly offenders in their area of work.

A total of 220 referrals were searched with only 9 patients >55 years. Index offenses, mental disorder diagnoses, physical comorbidities including cognitive assessments in the form of memory tests and brain imaging were also collated for identified patients from electronic patient records.

Index offences included violence against person, arson, homicide, robbery, threatening behaviour and dangerous driving and affray. Diagnoses included learning disability, delusional disorder, paranoid schizophrenia, bipolar affective disorder, alcohol dependence, personality disorder and depressive disorder.

Patients had multiple comorbidities such as diabetes, COPD, hypertension, coronary artery disease and musculoskeletal problems. Out of the nine admitted patients, only six had an ACE with an average score of 70.83. Five patients had brain imaging, with two normal results and the others showing some degree of atrophy and ischemic changes.

Discharge destinations included medium secure units, low secure unit and prison. One patient unfortunately died during admission and four are still inpatients.

A staff survey conducted showed their perspective on the challenges in managing elderly patients and whether Wathwood Hospital had the appropriate resources for them to work with elderly offenders in their area of work. All results will be explained through tables and graphs.

It's evident that there are challenges in managing elderly patients in units not specifically designed to manage them. This is also due to the lack of geriatric training and resources available to allied health care professionals to carry out their respective work. It's therefore crucial we formulate more inclusive strategies to address these challenges.

To evaluate the use of antipsychotic polypharmacy in Ravenswood House Medium Secure Hospital. We also aimed to review the reporting of the outcomes of their use.

The use of antipsychotic polypharmacy (APP) continues to be practised within forensic psychiatric inpatient settings yet there is a lack of robust evidence for the benefits of doing so. The practice is also associated with the use of higher total antipsychotic doses beyond the recommended BNF maximum. Such prescribing is associated with an increased side effect burden. Doctors have a duty to justify the ongoing use of antipsychotic polypharmacy and to avoid potentially ineffective and/or harmful use.

A cross-sectional review of the medication cards for 51 in-patients at Ravenswood House Hospital was completed. Demographic data and data pertaining to diagnoses and medication was also gathered from the electronic patient records.

23 patients (45%) in Ravenswood House Hospital were prescribed antipsychotic polypharmacy. 87% of those prescribed antipsychotic polypharmacy had a primary diagnosis of either schizophrenia or schizoaffective disorder. 19 patients (37%) had two regular antipsychotics prescribed. 74% of these prescriptions were above the recommended BNF maximum. 62% were also prescribed a regular benzodiazepine. The vast majority of indications documented for APP were chronic behavioural disturbance and treatment resistant schizophrenia. The majority of these patients were on a T3. There was a significant under reporting of the rationale of prescribing APP. It could be surmised that at least 11 combinations were in part to mitigate side effects, but only 3 had this documented. There was also a lack of documentation or use of rating scales regarding the clinical outcomes and side effects of APP.

Prescription of antipsychotic polypharmacy is an important issue in secure forensic hospital settings. The lack of clear documentation of clinical effectiveness and side effect burden remains a concern. Wider study is required to establish the benefits of such prescribing to justify its ongoing use.

An audit on capacity assessment and consent to treatment on inpatient visits to Atherleigh Park Hospital was performed using the Mental Health Act Code of Practice as a framework. Six standards were evaluated:

1) documentation of capacity assessment in patient care records

2) documentation of patients who display a lack of capacity

3) completion of a Section 58 and/or 62 for detained patients

4) documentation of medicines on T2/T3 form and if they match with the patient's prescription chart

5) evidence of medication concordance and monitoring of adverse side effects

6) patient education on medicines prescribed for them

Inclusion criteria included patients who were detained under Sections 2, 3 and informal admissions, who were admitted for 72 hours or more, between October and December 2019. This gave a total sample size of 75. Data were collected by looking at patients’ care records and if applicable, their Section paperwork to identify any documentations related to the standards evaluated as above. Data collected were transcribed to a web link, downloaded and analysed.

In standard 1), it was found that 77% of the capacity assessment and consent to treatment forms were recorded in patient care records. Of these, 100% of were completed by a medic and 99% of all sections in the form were completed. However, only 57% of patients were re-assessed when their capacity and consent changed during admission. In standards 2), 3) and 4), documentation of patients who lacked capacity, completion of a Section 58 or 62 form and charting of medications on the T2/T3 forms were fully compliant. In standards 5) and 6), 76% of medication concordance were documented in patients’ records. Only 39% of adverse effects from medications were documented but monitoring compliance was 100%. Medication counselling was done infrequently, with 47% of patients given a leaflet and 28% educated on their side effects.

Action plans were identified. Firstly, to link the capacity assessment form with patient electronic ward round notes to ensure clinicians complete it at the end of a review. In order to monitor adverse effects from medications, physical examination, blood tests and ECG are to be done following a new prescription, and to be repeated if indicated. Information leaflets on common psychiatric medications are to be made readily available for patients. The findings from this service evaluation and the actions plans were shared with doctors. A re-audit is vital to re-evaluate the hospital's compliance.

Gloucestershire Health Care Trust operates an “all age” out of hours on-call rota, staffed by Registrars and Consultants who cross-cover all psychiatric sub-specialities. Our aim was to understand the challenges faced by psychiatrists of different professional backgrounds when assessing under 18 year olds in a health-based Place of Safety (POS).

We circulated a survey to all psychiatrists on the on-call rota, to gather quantitative and qualitative information on the challenges posed by assessments of under-18s in a POS and assess whether an under-18 specific policy was needed.

Out of the 50 psychiatrists invited, 27 completed this survey (during February 2021). 33.3% of respondents reported that they had completed a POS assessment of an under 18-year-old when a Consultant Child and Adolescent Psychiatrist/Registrar was not available to join. 33.3% of respondents had been asked to complete such an assessment as the sole psychiatrist joining the AMHP, with 24% of those respondents reporting feeling uncomfortable doing these assessments without a second doctor present, and an additional 24% feeling comfortable only sometimes. 48.1% of the doctors surveyed did not invite parents or carers to take part in the assessment, despite this being considered best practice, citing reasons such as: being unaware that this was a possibility, assessments conducted at unsociable hours, safeguarding concerns involving the parents, and social distancing in the context of COVID-19. 41% of respondents had assessed vulnerable young people (children looked after or with a diagnosis of an autism spectrum condition) in the POS and reported that these assessments posed significant challenges to safe discharge planning and identifying appropriate placements. 81.5% felt that a tailored policy for young people was needed. Qualitative findings suggest psychiatrists think such a policy should include clear procedures (flowcharts), potential outcome scenarios/options for safe discharge, referral criteria for CAMHS, contact details for key staff members, a handover protocol. Respondents felt a shared policy with all stakeholders (AMHP service, Mental Health Services, police) was required.

Our survey highlights the challenges for non-CAMHS specialists assessing under 18s in a health-based POS and the need for an under-18 policy to support safe practice. Major themes will be further explored in a focus group to guide policy development.

1) To assess the average wait time for patients to be offered an appointment and to establish any correlations between longer waiting times and 'Did not attend (DNA)' rates 2) To assess the number of patients who have opted into the text message appointment reminder service and whether this had an effect on DNA rates.

Research has indicated that the Did Not Attend (DNA) rate in Psychiatry is estimated at 20%, twice that of other medical specialties (1). With NHS Digital estimating that DNAs cost the NHS £1 Billion per annum, there has been much interest in reducing the rate of DNAs within Psychiatry (2). Findings have shown that short waiting times are associated with higher rates of attendance (3). In addition, poor appointment attendance within Psychiatry is also associated with increased disease severity and higher rates of hospital admission (4).

We conducted retrospective data collection on 99 patients referred to Professor Oyebode between January 2018 and August 2019. Our data collection involved assessing time the referral was received, time to first appointment and the patient's communication preference (e.g. whether they opted in to the SMS alert service). All data collection was conducted through use of RIO and coded/ammonized into a Excel spreadsheet. No sampling methods were employed and our population only consisted of first-time referrals to Professor Oyebodes clinic.

1) We found no correlation between a longer waiting time to first appointment and an increased DNA rate.

2) All patient waiting times between 1st January - 31st August were within the maximum limit set by national guidelines

3) Opting into the text messaging service remains severely low. Of the patients audited, 95% had not completed a communication preference form. Overall, it is still unclear whether the text messaging service has a positive impact on DNA rates.

Our data have shown no significant correlation between a longer waiting time and an increased DNA rate for first time Psychiatry appointments. Secondly, we have concluded that between the audited period, waiting times were still within the maximum 18 week wait set by the Mental Health Standards. Finally, we can conclude that uptake of the text messaging service remains very low at 4%. Due to a limited sample size of only 4 patients, it is still unclear from this audit whether opting into the text messaging services will have a positive decrease on the number of DNA's.

Statistically, suicide is less than half as deadly as poor physical health for people with severe mental illnesses (SMI). For every 1000 SMI patients, diseases such as diabetes cause 10-20,000 ‘years of life lost’ compared to 4,000 ‘years of life lost’ to suicide. National charity Rethink dubbed the failure of the NHS to act on this as tantamount to “lethal discrimination”.

We aim to reform the physical health care provision for service users under the care of Avon and Wiltshire Mental Health Partnership NHS Trust (AWP).

To evaluate the current service within AWP, we combined data from a comprehensive audit of 106 inpatients, local Quality Improvement (QI) Projects, and qualitative feedback from a pilot Medical-Psychiatric Liaison Service (MPLS).

Key findings included:

• High rates of physical comorbidities among psychiatric inpatients of all ages

• Novel illnesses occurring during admissions

• Evidence that patients are not receiving adequate physical healthcare from wider NHS

• Junior doctors receiving inadequate support from Seniors and acute Hospital services when managing physical illnesses

During the MPLS pilot, a Consultant Physician provided virtual ward rounds and advisory sessions. 100% of staff involved reported the service was beneficial for their clinical practice and patient outcomes.

Taking these findings and input from colleagues within AWP and nationally, we created a comprehensive strategic overview on how AWP can deliver high quality physical health care, detailing improvements to make across 5 key domains: Inpatient, Community, Workforce, Education and Information Technology (IT).

Presently, we are working with Clinical Commissioning Groups developing protocols clarifying roles and responsibilities across primary and secondary providers. We are standardising communication between AWP and primary care and expanding links with specialist secondary services (e.g. endocrinology and cardiology). We formed the BRIGHT (Better Recording of Information for Governance and Healthcare in the Trust) project workgroup alongside IT to build safer and more effective records systems.

Medium term recommendations include employing a full-time MPLS Consultant Physician, in addition to ‘Physical Health and Wellbeing Workers’ in all localities, Advanced Nurse Practitioners (working within structured physical care systems) and more allied health professionals (dieticians, speech therapists and physiotherapists).

In the long term, the new Physical Health, IT and QI working groups will maintain development of these proposals, improve training and supervision for clinicians, and achieve healthcare parity for patients across localities.

Unique challenges have been faced by women in the perinatal period during the COVID-19 pandemic and the impact of this is compounded for women suffering from mental illness. This service evaluation looked at different aspects of the treatment pathway on a specialist inpatient psychiatric Mother and Baby Unit during the pandemic to identify what changes occurred.

Data were collected for all admissions to the unit between January 2019 and October 2020, with the beginning of the pandemic being defined as on or after 1st March 2020. Information was collected retrospectively from electronic clinical notes on ethnicity, length of stay, diagnosis, mental health act use and restrictive practice, medication, psychology, occupational therapy and social services involvement.

There were 114 admissions to the MBU during the study period. 4 were parenting assessments rather than acute psychiatric admissions and were excluded from the analysis, giving a sample of 110 women. 58% (62/110) were classed as “pre-pandemic” and 43.6% (48/110) were “during pandemic”. 95.45% (105/110) of women were postpartum 4.55% (5/110) were pregnant. Mean length of stay was shorter during the pandemic at 44 days, compared to 61 pre-pandemic. There was greater use of the mental health act during the pandemic: only 43.75% of patients were informal throughout admission, compared to 70.97% pre-pandemic. Mean duration of detention was shorter at 25 days (32 pre-pandemic). Psychotic illness made up a greater proportion of diagnoses during the pandemic: 56% (27/48) compared to 44% (27/62) pre-pandemic. The next most common diagnostic group was mood and anxiety disorders, which made up 29% (14/48) of diagnoses during the pandemic, but 43% (27/62) pre-pandemic. Outcomes as measured using the Health of the Nation Outcome Scale showed a mean improvement between admission and discharge of 6.65, compared to 5.15 pre-pandemic. HONOS scores were higher on admission during the pandemic (12.83, vs 10.88), suggesting a higher level of acuity.

During the COVID-19 pandemic on this Mother and Baby Unit, length of stay was shorter, a greater proportion of patients were detained under the mental health act (although length of detention was shorter) and psychotic illness was more prevalent. This study demonstrates that there were differences in this perinatal inpatient population during the pandemic and this may be a reflection on the wider impact of COVID-19 on perinatal mental health.

To compare monitoring of lithium treatment with shared care lithium monitoring agreements in a large rural GP practice.

A ‘near miss’ event with a patient with drug induced long QT syndrome highlighted a need for an audit of lithium monitoring at a large rural GP practice.

The practice had entered into shared-care monitoring agreements with the local mental health care trust. Under these agreements, responsibility for physical monitoring of lithium treatment was assumed by the practice.

Using audit functions built into the IT system, all patients at the practice who were currently prescribed lithium-containing medications were identified (n = 28). Individual monitoring standards were determined for each patient based on the shared care agreement. These varied depending on age and comorbidity. Monitoring data obtained from medical records was compared against the individualised monitoring requirement.

The key finding was that 26% of patients for whom annual ECGs were indicated according to the shared care agreement had received an ECG in the past year. 78% of patients had a lithium level recorded in the previous 3 months. 81% of patients had a renal function test within their monitoring requirements. 52% of patients had lipid measurement in the previous year.

There is a great degree of heterogeneity in the extent to which shared care monitoring agreements are achieved. It is noted that those standards to which a Quality Outcome Framework incentive applied had a greater chance of being met. Worryingly, the QOF statements relating to lithium treatment have now been retired as of April 2019. It is suggested that psychiatrists are aware of the challenges primary care faces when monitoring lithium treatment.

To study the impact of collaborative working, via consultation liaison, between Mental Health Liaison Practitioners (MHLPs) and Doctors within a secondary care mental health service. We hypothesise that this model of working may avoid unnecessary clinic appointments and waiting times, whilst providing patients with more efficient treatment.

Mental health services are stretched, understaffed and under-resourced. It is estimated that 75% of people with mental health problems in England may not get access to the treatment they need. We therefore need efficient and innovative ways for people who seek help to receive support. Good practice consultation liaison involves face to face contact between clinicians; treatment can be delivered by supporting primary care whilst reducing the burden of secondary care mental health services.

Regular 30-minute sessions within an Assessment and Treatment Service, between MHLPs and Doctors, at both Consultant and Trainee level, were coordinated. Patients assessed by MHLPs were discussed by opening a dialogue whereby further management was discussed across a multi-professional team. A record was created of all patients discussed and the outcome.

Number of MHLP/Doctor sessions: 10 across a six-month period.

Number of patients discussed: 17.

Medication advice provided for 16 patients. One patient required a referral for a clinic appointment.

For several patients, integrated working procured alternative care pathways and resources to be considered, to incorporate into individual treatment plans.

Regular consultation liaison with MHLPs and Doctors is a model of working across the interface between primary care and specialist mental health services. It may provide patients with more efficient care, whilst avoiding unnecessary waiting times for clinic appointments. The consultation liaison working supported the development of an educative relationship between clinicians, with interprofessional learning. This is an example of an integrated and collaborative care model, whereby multi-professional working can provide efficient and effective treatment, whilst the support for the patient can remain in the primary care setting.

A service evaluation project to look at if annual bloods, ECG, physical examination, and medical review was completed within the last year for patients attending anti-psychotic depot clinic at Bassetlaw mental health services in Nottinghamshire HealthCare NHS Foundation Trust.

Electronic notes were examined in October 2020 for 25 patients who attend anti-psychotic depot clinic to ascertain if medical review and physical examination had been completed along with annual bloods and ECG.

Out of 25 patients attending depot clinic in 2020 at Bassetlaw Hospital, 21 had all their blood tests done, 1 patient had refused bloods and 2 patients did not have blood tests done. ECG was completed for 3 patients at Bassetlaw hospital and 8 patients had it requested from primary care with 2 patients refusing to have ECG done. For 12 patients there was no evidence of ECG being requested or completed. 8 patients had physical examination completed and rest 17 patients did not have the physical examination completed including due to refusal. Out of 25, only 14 patients had a medical review conducted.

Patients who attend depot clinic may have an allocated community psychiatric nurse (CPN) or get reviewed by medics in outpatient clinics and would usually have their blood tests, physical health examination and ECGs requested and monitored by them. Patients who do not have any allocated CPN or medic tend to miss out on blood tests and ECG. General Practitioners are expected to complete physical health checks for patients who do not have CPN or regular outpatient review. The results of these investigations may not always be received in depot clinic, hence there is no documentation on electronic RIO system. When these patients disengage from the depot clinic, it is often very difficult to track them. As a follow-up from this service evaluation, all depot clinic patients will be allocated a key worker/CPN. This will ensure that they have a responsible person to facilitate annual checks. This will be reviewed in a years' time to evaluate the effectiveness of this intervention.

To complete an audit cycle to investigate: trainees’ experiences of SI involvement since 2017, perceptions of current support systems and trust facilitation of learning from SIs and the impact of the interventions implemented following the 2017 survey.

In 2017, data were collected from trainees working in psychiatry within two London trusts to examine the nature of their involvement in serious incidents (SIs), their experience of the process following an SI and their knowledge of the support systems available to them. Due to concerning results from this, several interventions were put in place in accordance with trainees’ suggestions.

Cross-sectional surveys were e-mailed to trainees of all grades in July 2019, including GP and foundation doctors, working within two mental health trusts. These built upon the 2017 surveys, additionally enquiring about demographic information and the personal and training consequences of SIs on trainees.

61 (15% of all trainees) returned the survey with 41 (67%) respondents unable to recall any SI related teaching during induction and 47 (77%) not having received a written guidance document on SI procedures.

24 (39%) had been involved in an SI. Only half felt adequately supported by the trust at internal investigation. Knowledge of the available internal and external sources of support ranged from 38-71% however these sources were rarely utilised. 12 (60%) trainees did not feel that learning had been facilitated following an SI and almost none had been informed of internal investigation outcomes.

Respondents who gave a low (1-4/10) rating of support from their NHS Trust were more likely to have been informed about the incident in person, been invited to team-based support or been aware of the variety of sources of support available, when compared with respondents who scored their Trust support more highly. Suggestions for improvements made by trainees included opportunities to observe coroners’ inquests and a peer support scheme from colleagues with experience of SI involvement.

Unfortunately, trainees did not report much improvement in their experiences compared those in the 2017 survey, and a large proportion continued to feel unsupported. Interventions had not been as widely circulated as intended and only half of trainees had been invited to team-based support. Possible further interventions include increasing email communication to trainees following SIs and setting up a peer support scheme. We are in the process of organising a coroner's inquest observation programme for trainees.

To ensure that the PPE guidance is strictly adhered to.

To ensure that patient care is not compromised.

To help us in areas of need in order to educate the staff regarding the techniques of PPE and thus ensure patient and staff safety and care during the pandemic.

Novel coronavirus 2019 was first described in December 2019 in Wuhan in China. Since those initial few cases, it has rapidly proliferated to a global pandemic, putting an inordinate amount of strain on healthcare systems around the world. We believe that the technique of donning and doffing if followed as per PHE guidelines would be of help in both preventing the infection and improve the care and safety of both patients and staff.

This Audit includes both In-patient and Out-patient units in Psychiatric services across North Wales. Data were collected from 19 units out of 39. We observed covertly 325 staff members belonging to various cadres. Apart from the Donning and Doffing techniques, we also observed the availability of designated areas for this purpose and the availability of PPE as well.

Data collection was by junior and senior doctors from various sites of the mental health unit in North Wales. A proforma was provided, the standards were based on PHE guidelines.

It was noted that just about 50% of the staff followed donning as per guidance. Amongst all three sites, the Central team showed a better adherence with 85% of them donning PPE correctly. whereas only 22% adhered to donning in the West team.

Only 21% of them managed to doff PPE as per guidance amongst all 3 centres in North Wales.

It was also noted that there are no designated areas to Don and Doff in outpatient units. Staff, in general, seem to not adhere to the guidance of utilising a mask, especially when within 2 meters distance of other staff.

We will be presenting the Audit at the regional meeting. After discussion with the infection prevention control team and Health and safety lead, we intend to improvise the wards with designated areas for donning and doffing. Teaching sessions for the staff in all three sites, reminders in various areas of the community mental health units and inpatient units.

We are hoping that these recommendations will help us in achieving our aim of health and safety during this pandemic.

The aim of this retrospective analysis was to look at the effect that telehealth had on patient outcomes and the therapeutic alliance.

Clinical outcomes measures were collected prospectively as part of routine clinical care. Outcome measures were administered at patients’ initial and final appointment. Information was merged into a single database and imported into IBM SPSS for retrospective analysis. The following measures were administered at the beginning and end of treatment and were used to evaluate patient progress; Health of the Nation Outcome Scale (HoNOS), Life Skills Profile (LSP), Session Rating Scale (SRS), Outcome Rating Scale (ORS).

Two cohorts were derived from the clinic; the first cohort (n = 90; 53 females; 37 males; M = 35.72 years; SD = 12.12 years) comprised of those patients whose care occurred between 23/09/2019 and 22/03/2020 and did not receive telehealth appointments. The second cohort (n = 122; 68 females; 54 males; M = 36.2 years; SD = 12.78 years) were those patients who presented to the clinic and were discharged between 23/03/2020 and 21/09/2020 and received at least one telehealth appointment. In the pre-telehealth cohort, mean HoNOS scores at baseline were 17.87 compared to 13.53 at discharge, mean LSP scores at baseline were 10.76 compared to 9.01 at discharge, mean SRS scores at baseline were 34.17 compared to 36.04 at discharge, and mean ORS scores at baseline were 12.97 compared to 21.28 at discharge. In the post-telehealth cohort, mean HoNOS scores at baseline were 14.45 compared to 10.50 at discharge, mean LSP scores at baseline were 7.85 compared to 7.19 at discharge, mean SRS scores at baseline were 36.04 compared to 35.36 at discharge, and mean ORS scores at baseline were 18.83 compared to 15.85 at discharge.

Results show that telehealth did not impact negatively on the therapeutic effect of clinical sessions, highlighted by similar reductions in HoNOS and LSP scores. It was seen in the post-telehealth cohort that there was worsening in the subject-rated scales (SRS and ORS) which was not seen in the pre-telehealth face-to-face cohort. Thus, there seems to be a discernible negative difference from the patient's perspective in the clinical sessions. This may be due to the difficulties in therapeutic alliance using the telehealth platform. We appreciate that there are a number of confounding factors, especially the effect of COVID-19 isolation. Telehealth is a useful addition to our assessment and treatment paradigms and its use should continue; however, we should be aware of the potential negative effect on therapeutic alliance.

Recent local research examined mortality rates following admission to a dementia ward. We wanted to expand on this work and include other important health outcomes for patients admitted to our specialist in-patient dementia unit in the west of Scotland. This would provide a comprehensive overview of our in-patient population, aid service review and improve care. We hypothesised that patients admitted would be physically frail, have a significant mortality rate and would likely require long-term care post discharge.

The clinical notes for each admission to the unit for one year were examined (total 62). We extracted data from a number of different areas such as demographics, mortality rates, discharge destination, readmission rates and prescribed medications.

60% had an Alzheimer's/mixed dementia diagnosis. Average length of stay was 64 days. 62% were discharged to a care home (50% of this total had lived at home prior to admission), 18% to complex care and 20% to the community. 66% were prescribed an antipsychotic and the average number of medications was 8.4. 35% had a readmission under general medicine within a year of discharge. 19% died whilst an inpatient and a further 30% had died one year post-discharge (total one-year mortality of 44%).

People admitted to our dementia unit are physically frail, with only 20% returning to live in the community, 35% being readmitted to a general medical ward within a year of discharge and 44% dying during the admission or within a year of discharge. We need to bear these results in mind when considering if hospital admission is appropriate and ultimately further develop our skills in palliative and end of life care in order to provide those people admitted to our dementia unit (and those who remain at home) with the highest standard of care.

To audit the current practice of pharmacological management of Borderline Personality Disorder with NICE Clinical guideline [CG78]: Borderline personality disorder:

Objectives:

23 patient records were analysed in the last 18months with a diagnosis of EUPD to compare current practice against NICE clinical guidance. (2009)

Standards:

When prescribing

1. 1) Use a single drug.

2. 2) Use the minimum effective dose.

3. 3) Agree with the person the target symptoms, monitoring arrangements and anticipated duration of treatment. Antipsychotic drugs should not be used for medium, long term treatment.

   Indication:

4. 4) Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated. (Repeated self-harm, marked emotional instability, risk taking behaviour and transient psychotic symptoms).

5. 5) Short-term use of sedative medication may be considered cautiously as part of the overall treatment plan in a crisis. The duration of treatment should be no longer than 1 week.

6. 6) When considering drug treatment, provide the person with written material about the drug. This should include evidence for the drug's effectiveness in the treatment of borderline personality disorder and for any comorbid condition, and potential harm.

   Review:

7. 7) Review the effectiveness and tolerability of previous and current treatments.

8. 8) Discontinue ineffective treatments.

Borderline Personality Disorder is common in psychiatric settings with a reported prevalence of 20%.

As per NICE Guidance (CG 78), no medications have been found effective for the longer term treatment of personality difficulties.

This audit was carried out to review if patients were offered psychiatric reviews to discuss the medications they are using, the effectiveness of these, and any potential side effects.

Good practice compliance of 90-100% was noted where >90% compliance was seen in areas where the effectiveness and tolerability of current and previous medication was reviewed by the clinicians under Structured Clinical Management. Also was noted that antipsychotics were not used for medium to long term in patients with Borderline Personality Disorder in the cohort.

The following areas were non-compliant with the NICE recommendations where a compliance <79% has been achieved.

When prescribing, use a single drug (avoid polypharmacy), agree target symptoms, monitoring and duration, provide written information, discuss evidence for effectiveness in treatment of borderline personality disorder.

Partial compliance was achieved (80-89%) with use of sedatives for less than 1 week and discontinuation of ineffective treatment.

Distribute key cards to clinicians.

Provide written information to patients.

Re-audit in 6 months.

Following a Care Quality Commission (CQC) outcome showing that capacity assessments were not routinely completed on admission of patients we decided to complete an audit on current practice. We planned to review admission clerkings at Chorley Mental Health Inpatient Unit to assess quality, with the overall aim of putting measures in place to improve standards. We planned to make the results reflective of all psychiatry wards within Lancashire and South Cumbria NHS Foundation Trust (LSCFT) with the addition of a qualitative survey.

We are aware the standard of clerkings can vary and affect patient care. CQC outcome showed that that capacity assessment was not routinely documented and consultants have stated that clinical impressions are rarely documented in junior doctor clerkings. This audit allowed us to objectively assess these observations. We believed the results may show common themes throughout psychiatric practice more generally.

The gold standard was a 20 item list of expected components of a clerking, based on trust guidelines. A snapshot of current inpatients (n = 30) on 31/10/19 was taken. An Excel sheet was used for information gathering. Data were analysed and graphs created. A qualitative questionnaire on current practice was sent to trainees (n = 8) on different sites for an overview of practice across LSCFT. Therefore, a mixed-methods model was employed.

Items with the highest completion included clerking within 6 hours, face-to-face review with consultant completed within a week and current medication documentation. The items with the lowest completion included clinical impression documentation, bloods completed within 24 hours and documentation of capacity assessment and smoking/substances history. Common factors between clerkings with fewer completed items included poor patient engagement and patient transfer from another ward.

Qualitative survey (n = 8) showed that junior doctors across the health board are not using uniform methods for capacity documentation or an official checklist for clerking.

We concluded that the low rate of capacity assessment completion was an important finding due to legal implications, and that there should be a uniform place for documentation of this. Physical health consequences of other missing components were explored. We will introduce standardisation of capacity assessment documentation and use of a clerking checklist, before re-auditing. The results were presented at local teaching and recommendations sent to Site Tutors for inclusion in local inductions.

This project aims to examine a group of service users over the age of 65 with functional presentations, who were assessed by the Liaison Psychiatry team between June 2018 and 2019.

Hypotheis: We believe that there is a need for a community crisis service for the older adult North Derbyshire population with functional presentations.

Due to the lack of community crisis services for patients over 70, it was felt that a significant number of these patients were admitted to inpatient psychiatric units from medical wards who would benefit from crisis intervention instead. We wanted to see the clinical outcomes of this population, referred to the liaison team, determining whether this was significant concern. If this need is established, based on the data collected, this will enable the trust to look into starting a service for this age group to provide care in their own home. In turn, it will help to reduce unnecessary admissions to acute mental health wards and reduce stays in the general hospital – preventing consequences associated with long term hospital stays.

Retrospective analysis using PARIS notes of 366 patients referred to the liaison team were scrutinised to determine the assessment diagnosis and outcome of patients with functional conditions. The inclusion criteria were patients over the age of 65 referred with functional psychiatric illnesses between June 2018 and 2019. We excluded 84 patients assessed to have delirium or organic presentations from our analysis. Data were collected and analysed using Excel.

Among the referrals to the liaison team, the majority of patients were referred with mood disorders followed by self-harm, psychosis and anxiety. Although the majority of patients were referred back to either the community mental health team or primary care, 11% of the sample were admitted to inpatient psychiatric units. This number may have been lower and admission may have been avoided if a community crisis service was in place for this population.

In conclusion, the data support our initial concerns that there is a need for crisis services for this age group with functional presentations. There is ongoing discussions around a need to develop this service and therefore our results will contribute to the development of an older adult functional service in Derbyshire.