BOARD / Date of Meeting: 19 July 2017
Subject : / Consultation on dementia home treatment team and fan gorau
Approved and Presented by: / Alan Lawrie, Deputy Chief Executive and Director of Primary and Community Care
Hayley Thomas, Director of Planning and Performance
Prepared by: / Adrian Osborne, Assistant Director (Engagement and Communication)
Other Committees and meetings considered at: / PTHB Executive Committee, Mental Health and Learning Disabilities Assurance Committee, Finance Planning and Performance Committee, PTHB Board, Powys CHC Montgomeryshire Area Committee, Powys CHC Executive Committee
PURPOSE:
The purpose of this paper is to:
- Summarise the engagement and consultation process in relation to Dementia Home Treatment and Fan Gorau in north Powys
- Recommend to the Board that the Dementia Home Treatment Team in North Powys is permanently established and Fan Gorau is permanently closed as a mental health inpatient assessment unit
- Describe the range of assurances that support this recommendation and would be put in place if the recommendation is approved
Discussion
Information
THE PAPER IS ALIGNED TO THE DELIVERY OF THE FOLLOWING STRATEGIC OBJECTIVE(S) AND HEALTH AND CARE STANDARD(S):
Strategic Objectives: / SO2: Improve the emotional wellbeing and mental health of the people of Powys
SO5: Deliver continuous improvement in safety, quality and patientand carer experience in all settings
SO10: Develop partnership working to achieve the ambitions of the health and care strategy and the Powys Wellbeing Plan
SO12: Develop a sustainable, skilled, engaged and content workforce fit to meet the needs of the population of Powys
Health and Care Standards: / Dignified Care, Timely Access, Planning Care to Promote Independence, Listening To and Learning From Feedback.
EXECUTIVE SUMMARY:
Quotes from Carers about the Dementia Home Treatment Team
“Feeling great, excited about this going forward; this is brilliant, inspiring!”
“Thank you for doing this, keep going”.
“I wish I could have had this when my husband was a dementia patient!”
“This can’t help us because my husband is now deceased
but it can help many others”.
“I have a feeling that Welsh Government will
shower you with funding for this”.
“Having the support of the Dementia Home Treatment Team is invaluable,
no one should ever walk alone, we should all walk together”.
“When Fan Gorau closed I was disappointed, but now if you stopped the Dementia Home Treatment Team I would see that as a human rights issue”.
Background
The Fan Gorau Inpatient Assessment Unit in Newtown closed on 13 June 2016 due to safety concerns arising from the inability to maintain safe 24-hour staffing.
In response to this a Dementia Home Treatment Team was established in North Powys to provide home-based support for people with dementia and their families and carers, along with a “crisis bed” at Crosfield House in Rhayader to provide access to overnight care alongside the other services provided and commissioned by PTHB (e.g. Redwoods in Shrewsbury, Llandrindod Wells Hospital where the mental health services at the time of the initial closure were provided by ABUHB but have since transferred to PTHB, and Tawe Ward in Ystradgynlais which at the time of the temporary closure was the only alternative facility provided by PTHB).
The decision to temporarily close the service in response to challenges maintaining the inpatient service was a difficult one, but it was the right decision to make on grounds of service safety. Repeated attempts to recruit to vacancies in the team have not been successful and the service has now remained temporarily closed for over a year.
During that time the Dementia Home Treatment Team established in its place has been positively received by service users, families, staff and stakeholders. The service has been in place from 0730 to 2030, seven days a week to support people in their home.
Given the positive experience of the Dementia Home Treatment Team and the continued recruitment challenges to the 24-hour inpatient assessment service, a six-week programme of engagement was agreed with Powys Community Health Council during February and March 2017. This demonstrated positive support for the Dementia Home Treatment Team model alongside a number of issues and assurances that had been identified by service users, families & carers, staff and stakeholders.
In response to this feedback, a further four-week period of formal consultation was agreed with Powys Community Health Council on a proposal to permanently establish the Dementia Home Treatment Team in North Powys and close Fan Gorau inpatient assessment unit. This took placefrom 12 June 2017 to 10 July 2017.
More information about the background to this programme of engagement and consultation can be found in Sections 1 and 2 of the attached report.
Engagement
Extensive engagement took place during 2016/17. A detailed Engagement Report and interim Equality Impact Assessment was presented to CHC Executive Committee on 30 May 2017 and an update was presented to PTHB Board on 31 May 2017 as part of the Strategic Change report.
During the engagement we heard high levels of support for the Dementia Home Treatment Team model and people shared their experiences of how it had supported people to remain at home. Particularly in the Newtown locality, we heard some anxiety if the inpatient facility did not re-open. Staff shared their concerns about the continued uncertainty and their desire for the Dementia Home Treatment Team to be established permanently so that they could embed this way of working and the benefits they felt it offered for patients.
More information about the engagement process and findings can be found in Section 3 of this report.
The Engagement Report and Engagement Plan are included in the Annexes to this paper. The interim Equality Impact Assessment report is available on request, whilst the updated Equality Impact Assessment Report is included in the Annexes to this paper.
The Board is asked to NOTE the Engagement Report (Annex B) and Engagement Plan (Annex C).
Consultation Process and Findings
Findings from the engagement were presented to CHC Executive Committee on 30 May 2017, and discussed with PTHB Board on 31 May 2017 via the Strategic Change report. On the basis of the engagement findings, a four-week period of consultation on a proposal to permanently establish the Dementia Home Treatment Team in North Powys and close Fan Gorau inpatient assessment unit was approved.
Formal consultation was launched on 12 June 2017 and concluded on 10 July 2017. It has been delivered in accordance with the Consultation Plan presented to the CHC Executive Committee on 30 May 2017, building on the requirements set out in the NHS Wales guidance on engagement and consultation on service change.
An overview of the consultation process and findings can be found in Section 4 of this report.
The Equality Impact Assessment report and the Consultation Plan are included as Annexes to this report.
The Board is asked to NOTE the Equality Impact Assessment (Annex A) and Consultation Plan (Annex D)
The Board is asked to NOTE AND DISCUSS the findings from engagement and consultation (set out in Sections 3 and 4)
Conclusions and Next Steps
The findings from consultation showed a high level of consistency with the findings from ongoing engagement and have helped us to strengthen our understanding of the aspirations and concerns of stakeholders, and to ensure that these are addressed.
Based on this period of consultation it is recommended that the Dementia Home Treatment Team for North Powys is permanently established and Fan Gorau is permanently closed, subject to a range of assurances which are discussed in more detail in Section 4.7.
The Board is asked to AGREE the recommendation that the Dementia Home Treatment Team for North Powys is permanently established and Fan Gorau is permanently closed as an inpatient assessment unit, and to AGREE the key assurances identified in this paper, noting that implementation will be reviewed through the Mental Health and Learning Disabilities Assurance Committee and Montgomeryshire Committee of Powys Community Health Council after six months following transitionand on an ongoing basis if agreed at those meetings (Section 4.7).
RECOMMENDATIONS:
The Board is asked to:
- NOTE the Equality Impact Assessment, Engagement Report, Engagement Plan and Consultation Plan.
- NOTE AND DISCUSS the feedback received during Engagement and Consultation.
- AGREE the recommendation that the Dementia Home Treatment Team for North Powys is permanently established and Fan Gorau is permanently closed as an inpatient assessment unit, and
- AGREE the key assurances identified in this paper, noting that implementation will be reviewed through the Mental Health and Learning Disabilities Assurance Committee and Montgomeryshire Committee of Powys Community Health Council after six months following transition, and on an ongoing basis if agreed at those meetings.
NEXT STEPS:
- Communication to staff and stakeholders
- Permanent establishment of Dementia Home Treatment Team
- Six-month review via Mental Health and Learning Disabilities Assurance Committee (29 January 2018) and Montgomeryshire Committee of Powys Community Health Council (23 January 2018)
Impact Assessments
Equality Act 2010: / An Equality Impact Assessment has been undertaken and is included with this paper.
Quality and Safety: / The Dementia Home Treatment Team has been developed in response to quality and safety concerns arising from inability to maintain safe and sustainable staffing. Quality and Safety issues have formed part of our non-financial options appraisal.
Welsh Language (Wales) Measure 2011: / Engagement and consultation materials have been provided in the Welsh medium. Impact on Welsh Language has been considered as part of the Equality Impact Assessment.
Financial Implications: / The preferred option does not have an adverse financial impact for the health board and supports us to provide more care for more individuals within the same resources.
Legal Implications: / The process of engagement and consultation is consistent with statutory requirements and guidance for engagement and consultation on service change. This includes the NHS Wales Guidance on Engagement and Consultation on Service Change, Community Health Council Regulations and related legislation and guidance.
Well-being of Future Generations (Wales)Act 2015: / The preferred option supports wider ambitions for the Wellbeing of Wales, particularly in relation to a Healthier Wales. In addition, the next phase of work will be supported by our continued partnership working on the Social Services and Wellbeing Act including the production of the first Area Plan for Powys.
Update on Fan Gorau and Older Adult Mental Health Services in North Powys
For presentation to
Powys Teaching Health Board and
Powys Community Health Council Executive Committee
July 2017
Version 1, 11 July 2017
Authors:
•Hayley Thomas, Director of Planning and Performance
•Adrian Osborne, Assistant Director (Engagement and Communication)
•Neil Miles, Assistant Director (Planning)
•Joy Garfitt, Assistant Director (Mental Health Services)
•Mandy Mills, Engagement Officer
1.Background:About Fan Gorau
Fan Gorau is an 8 bed mental health inpatient assessment unit for adults at the Montgomeryshire County Infirmary in Newtown.
It provides inpatient assessment for people with organic mental health issues, such as dementia.
Typical service occupancy is between 3 and 6 patients at a time.
Feedback from staff indicates that many patients could be cared for at home or close to home if a greater level of community support was in place.
It has a nursing establishment of 7.53 whole time equivalent (wte) registered mental health nurses (RMHN).
Responsibility for the management of Fan Gorau transferred from Betsi Cadwaladr University Health Board (BCUHB) to Powys Teaching Health Board (PTHB) in December 2015 as part of a wider ongoing transfer of direct management of mental health services from neighbouring health boards to PTHB.
Sustainability of services from Fan Gorau has been an ongoing issue over a number of years, and a previous programme of engagement took place in 2009.
2.Context for Engagement & Consultation:Position as at February 2017
This section provides an overview of the context and background that led to the engagement and consultation process that is summarised in this report.
Fan Gorau has been temporarily closed to admissions since 13 June 2016.
The temporary closure was due to significant patient safety concerns arising from sustainability of levels of qualified staffing. The unit has 2 RMHN vacancies within the team (26.6% of the workforce), compounded due to sickness absence and during times of annual leave and other planned leave.
Vacancies presented a challenge to the sustainability of the service prior to and post the transfer of the service from BCUHB to PTHB.
Safe staffing requires an RMHN to be on duty 24 hours a day. This level of vacancies and other staff absence meant it was not possible to cover all operational shifts with substantive or bank registered staff.
Prior to temporary closure, the unit had drawn extensively on agency RMHN staff to cover shifts (especially nights, in the absence of bank staff). Sustained use of agency staffing as the only registered member of staff is not a safe staffing model.
The Health Board assessed the available options and following discussing with Powys Community Health Council the temporary closure was agreed in accordance with Regulation 27(5,7(d)) of the Community Health Council Regulations as an urgent service change decision to be taken immediately because of the risk to the safety or welfare of patients.
A patient, public and stakeholder communication plan was implemented to announce a temporary closure of Fan Gorau from 13 June 2016 to December 2016. This period would allow further initiatives to secure sustainably safe staffing.
During this time renewed recruitment efforts were made. This included advertisements in local media (e.g. Wrexham Leader, Shropshire Star), social media campaigns, recruitment posters, NHS Jobs coverage and links with local Universities. Overall, these posts were advertised on 11 separate occasions but this did not attract suitable applicants to ensure safe staffing levels.
The renewed efforts were unsuccessful and the unit remains closed.
2.1 Transition
At the time of the temporary closure in June 2016, there were three inpatients on Fan Gorau. In collaboration with clients and family they were transferred to Clywedog ward in Llandrindod and Tawe Ward in Ystradgynlais.
We acknowledge that where transfers took place to Tawe Ward in Ystradgynlais this involved considerable travel for visiting, and that ongoing family and carer contact is an essential element of the care pathway. The health board received two formal complaints relating to the transfer of patients to alternative inpatient facilities.
2.2 Interim Service Model: Dementia Home Treatment Team
Following the temporary closure of Fan Gorau, the staffing team were deployed into the community to deliver a Dementia Home Treatment Team (DHTT).
The service operates from 0730 to 2030 seven days a week. It provides intensive support to patients in their own homes, in nursing /residential homes and in community hospitals. This enables more people to remain at home or close to home, reducing the need for hospital admission. It supports people with dementia to be supported in a familiar environment, reducing the anxiety and distress that can be associated with transfer to an unfamiliar care environment.
The team also provides support to Residential and Nursing care homes in north Powys in order to support their residents with complex needs.
Referrals to the team are accepted from General Practice, Community Mental Health Teams, Residential & Nursing Care Homes, general wards in Powys’ community hospitals and directly from patients & carers.
Outside the operating hours of the Dementia Home Treatment Team (i.e. 2030 to 0730, seven days a week), urgent assessments are made through the Emergency Duty Team and a Psychiatrist on call continues to provide cover in the out-of-hours period.
Based on the assessment provided by the Dementia Home Treatment Team (or Emergency Duty Team) the treatment and care pathway may include:
- Putting in place a package of care to enable the individual to remain in their current setting (e.g. home, residential or nursing care home, community hospital).
- Short term crisis care through a crisis bed commissioned at Crosfield House Nursing Home in Rhayader. We continue to review the location of the crisis bed – based on availability of MH Nursing Home beds and the skill mix of staff to care for Patients requiring crisis care.
- Where patients have required hospital-based assessment and treatment (or detention under the Mental Health Act), new admissions have been accommodated as close to home as possible, based on individual needs and timely availability of a suitable bed. Options include Redwoods in Shrewsbury, Llandrindod, Brecon and Ystradgynlais.
As at February 2017, over 150 patients had been supported, assessed or treated via the Dementia Home Treatment Team. Fewer than 5% of these have required hospital admission.
Where hospital admission is needed, including under the Mental Health Act, a range of options is considered depending on the needs and circumstances of the individual and their family/carers. Potential options include Redwoods in Shrewsbury, Llandrindod, Brecon and Ystradgynlais.
2.3 Feedback from Service Users and Carers
The Dementia Home Treatment Team model seeks to ensure ongoing engagement of services users and their family/carers in care planning and delivery.
On discharge from the Dementia Home Treatment Team, patients (or more their family or carers) are offered a Patient Satisfaction questionnaire.
On the whole, patient and carer feedback is positive of the care patients have received.
Several compliments have been received. Two complaints have been received concerning patients admitted to wards outside of North Powys both of which relate to travelling distance to visiting.
“May I also take this opportunity to apologise for making a fuss when ***** was moved so far away. At the time I was stressed and angry wondering how would I be able to visit and how would he cope with strangers, but once he had arrived and settled I was relieved that he was in an exceptional hospital. Thank you all and especially the staff.”