A quality improvement project was undertaken to counteract obesity in patients with mental health morbidity. The exponential trend of increased antidepressant prescribing (SSRI, SNRI and anti-psychotic medication) has created a trend towards weight gain in patients. An audit of the Serious Mental Illness (SMI) register and depression registers was conducted in a population of 591 patients. Those patients identified as obese were offered referral to the local authority weight management services.

Patients have a body weight and BMI calculation with their twice yearly mental health and medication review and those whose BMI met the obesity criteria were offered referral to the local authority for 12 weeks weight management services.

Of the SMI and depression register 189 (32%) patients met the criteria for referral to the weight management program. Of these 154 (81%) patients accepted the local NHS weight management program, 35 (18%) of patients declined the NHS weight management program.

Weight gain is a known side effect of antidepressant medication SSRI and SNRIs and Anti psychotic medication resulting in increased risk of obesity and cardiovascular and metabolic disease. The QI program was undertaken to counteract these changes with referral to weight management services to address the weight gain the patients were experiencing.

This quality improvement service was done to help patients across three surgeries lose weight in an effective and educational manner. We found a high rate of acceptability of referral to weight management services when offered as patients themselves were aware of the weight gain. A review of positive changes in the BMI after referral to the weight management program will be undertaken at 6 and 12 months to evaluate its acceptability and effectiveness. We advocate sensitive counselling of the risks of weight gain and regular monitoring of body weight throughout the span of the prescribing of these weight gaining agents.

1. To assess quality of VTE risk assessment and recording; particularly to look at the impact of COVID-19 on VTE (Venous Thrombo-embolism). 2. To ensure VTE criteria have been adhered to from Tees, Esk and Wear Valleys NHS foundation trust 2019 ” Risk assessment for Venous Thromboembolism (VTE) (Ref: CLIN-0085-v 1.2)Specifically, due to additional risks posed by COVID-19 on increase in risk of VTE.

The Audit was conducted in Secure inpatient service in Teesside, Roseberry Park Hospital, TEWV NHS trust audit team.

This was done on the back of a scheduled Quality improvement reaudit of VTE risk assessment and recording review in Forensic SIS.

One of the main results was that VTE risk assessment and recording, post finding of a COVID-19 positive result was less than 100% in the records we checked. Other results are included in the poster.

The main conclusion is the need for increased vigilance in assessment and recording of (and any actions thereof) in the VTE risks, particularly in those with COVID-19 positive tests.

We propose that this increased vigilance will enhance patient safety and deliver effective and timely care. We highlight some challenges of conducting an Audit and how to embed results and improve practices in a timely manner. This describes how we did both- acted on results and followed process; rather than just one or the other!

To reduce incidents of inpatient violence and aggression at Nile Ward Psychiatric Intensive Care Unit (PICU), St Charles Hospital by at least 30% between December 2019 and December 2021. Reducing inpatient violence is a major quality improvement (QI) priority for CNWL NHS Foundation Trust.

Nile Ward refined a number of their successful change ideas within this project and a number of new innovative ideas were tested and successfully implemented as part of the Violence Reduction QI Project:

1. 1. Improved risk assessment tool: Risk assessment tool to predict/manage violence in the ward was further improved using evidence based observation and best practice recommendations over the course of 2021.

2. 2. Brand new Staff Photo Board: Regularly updated photoboard with non-hierachical list of all staff.

3. 3. Patient Feedback Board: Patient experience, comments and feedback displayed in common areas.

4. 4. Co-produced Mutual Expectations: A set of expectations created in co-production with patients displayed in the communal areas of the ward to be followed by both staff and patients.

5. 5. Gardening sessions: A safe socially distanced space for patients to be involved in growing and caring for the Nile Ward garden with our Activities Coordinator, including a brand new herb garden.

6. 6. Tailored Physical Fitness Programmes: Focus on physical activity through garden fitness sessions and 1–1 fitness sessions in the gym. Average weight gain for patients has declined from 4.4 kg to 2.8 kg (39% reduction) during hospital stay. Tailored physical fitness sessions created for patients who are frail, diabetic or have significant cardiometabolic risk factors.

7. 7. Celebrating Diversity: Special events hosted throughout the year to celebrate diversity and promote tolerance.

8. 8. Enhanced Clinical Reviews: Consultant led patient reviews every weekday to optimise treatment and enable quick recovery using a multidisciplinary, holistic, trauma informed approach.

9. 9. Weekly Cooking Sessions: Patient led cooking sessions using healthy ingredients every week. The food is eaten as a communal meal by patients and staff. A ‘Friday Fry-Up’ takes place monthly where patients and staff share a health fry-up in the ward's dining area.

10. 10. Mindfulness Meditation: A QI intervention introduced to embed mindfulness and meditation as core therapeutic intervention to improve emotional regulation and to reduce violence.

11. 11. Triangle of Care: Carers strongly encouraged to attend ward rounds and care planning from the very beginning of a patient's journey at Nile Ward using a triangle of care approach.

Between December 2019 - December 2020, Nile Ward reduced violence in the ward by 35% and the MDT continued to make further innovations to reduce violence further, as demonstrated in this poster.

Between December 2020 - December 2021, Nile Ward reduced violence in the ward by 51%.

Further details about the results will be published in the poster.

Nile Ward has successfully implemented innovative interventions using a QI methodology to successfully reduce the level of violence and serious incidents in the ward by 51%. The number of rapid tranquillisations and use of restrictive interventions such as restraints has reduced significantly. Our patients are able to recover in a safe environment and their feedback is testament to their positive patient experience during their inpatient stay. Reduced verbal and physical assaults on staff have improved staff confidence, retention, well-being and overall satisfaction. Our work has been recognised internationally through the delivery of keynote presentations at conferences National Association of Intensive Care Unit (NAPICU) National Conference 2021 & the Royal College of Psychiatrists National QNPICU Conference 2021 to discuss their Violence Reduction best practices with mental health teams in the United Kingdom and abroad.

To measure rates of racism experienced and witnessed by Junior Doctors working at Derbyshire Healthcare NHS Foundation Trust.

Surveys were sent out via e-mail and WhatsApp to all Junior Doctors from 22 November 2021 to 1 December 2021.

Questions asked about personal experiences of racism, witnessing racism to/from patients and/or staff whilst working in Derbyshire, knowledge of how to report incidents and if routinely reported. Doctor race and gender recorded.

88 Junior Doctors contacted. Response rate 55% (48 out of 88). 63% female, 35% male and 2% gender undisclosed. 37.5% White, 12.5% Black, 37.5% Asian, 6.3% Mixed-race, 4.2% Arab or other ethnic group and 2% Race undisclosed. 13% of doctors experienced racism from staff: 75% of the Black female population, 50% of the Black male population, 8% of the Asian female population and 17% of the Asian male population. 27% of doctors experienced racism from patients: 50% Black female population, 50% Black male population, 58% Asian female population, 16% Asian male population, 100% Mixed-race female population and 1 Race unspecified male. 13% of doctors witnessed racism from staff to other staff: 75% Black female population, 50% Black male population, 11% Asian female population and 16% Asian male population. 63% of doctors witnessed racism from patients towards staff: 75% Black female population, 50% Black male population, 67% Asian female population, 33% Asian male population, 100% of the Mixed-race population, 58% White female population, 83% of the White male population and by 1 male Race unspecified. Two reports of racism witnessed from staff towards patients. 50% of doctors do not know how to report racism. 54% of doctors would report racism if they knew how.

Black, Asian, and Minority Ethnic (BAME) Junior Doctors are disproportionately affected by racism with female gender as an additional vulnerability. Mixed-race females, Asian females, and Black doctors gave highest reported experience of racism from patients. Black doctors gave a higher reported experience of racism from staff and reported witnessing the most racism from staff towards other staff. Mixed-race and White male doctors represent a high number of those that witness patients be racist towards staff. Additional support is required in encouraging allyship, confidence and ability to report racism.

Patients with Functional Neurological Disorder (FND) often endure low quality of life. Understanding the diagnosis is critical to management, but patients with FND do not always receive appropriate information about their condition. The patient journey through healthcare services can be complex, with often long waits for specialist attention. Creating psychoeducation resources for patients is important to improve patient experience and outcomes. We developed a symptom self-management patient education booklet with an FND symptom recording template, using a co-production model, in a community neuropsychiatry setting.

We used co-production as part of a quality improvement project (QIP) at East Kent Neuropsychiatry Service, to produce a patient education booklet with symptom self-management information and a symptom recording template. The QIP cycle involved input from 11 participants. Initially, 3 medical students and 4 multi-disciplinary team members adapted an existing booklet, removing medical jargon and simplifying diagrams. The adapted booklet was distributed to patients with FND who were attending psychoeducation/Cognitive Behavioural Therapy group sessions. One week later, four patients discussed the booklet with a medical student facilitator; both quantitative and qualitative feedback was obtained. Feedback was gathered using an adapted 20 point Ensuring Quality of Information for Patients (EQIP) tool. Patient responses were recorded, and qualitative themes identified.

Four themes were found from qualitative feedback during co-production: need for a glossary; an expanded resource list; more diagrams to simplify text; and for the booklet to also address family, friends, and carers. The EQIP questionnaire feedback emphasised that the booklet contained too much medical jargon and that it didn't personally address the reader. On average patients scored the booklet 53.33% using the EQIP questionnaire.

The booklet was further adapted and a glossary, further diagrams and a section addressing family, friends, and carers was added. Further resources were added and the text was simplified for clarity.

This QIP shows the value of co-producing information for an underserved patient population. Patient psychoeducation is a key part of treatment; involving patients at an early stage of the development of information and self-management tools will increase their acceptability to patients and improve the accessibility of patient psychoeducation.

Clinical Team Meetings (CTM) are weekly multidisciplinary (MDT) meetings to review and discuss patients’ clinical care at Reaside Clinic, a medium secure inpatient forensic unit. Last year, there were significant difficulties in releasing nurses from ward duties to attend CTM, with effects on CTM efficiency and patients’ involvement and satisfaction in care. Furthermore, a hospital ‘protected mealtimes’ deadline commencing at 1230 meant additional pressure and further impacted patient attendance when meetings overran. The MDT (comprising doctors, nurses, psychologists, occupational therapists, pharmacists and admin staff) worked together to generate solutions, formulating a QI project to try to make improvements. Three primer drivers were: increasing patient satisfaction, increasing staff participation and increasing CTM efficiency.

The MDT generated multiple change ideas to test to improve CTM experience and outcomes. Actions implemented included review of timetabling of patients to ensure adequate timekeeping and ensuring availability of attending ward staff, defining patient expectations from CTM through increased communication, and seeking patient feedback on satisfaction or engagement after each CTM through anonymous questionnaires. Data were collected at CTMs from February to April 2022, retrospectively compared to reference data collected before QI actions were implemented. A Microsoft OneDrive document was shared between the MDT to ensure accurate data collection, with information collected on CTM finish time, number of patients offered to attend, number of patients who did attend and anonymous patient satisfaction feedback from questionnaires.

Early indications show improvement in meeting timelines and increased staff satisfaction with the CTM process, with data collection ongoing. Baseline results from September 2021 show an average of only 2 of between 13–15 patients attending weekly, in addition to finishing beyond the 1230 target on almost all occasions. Anecdotal evidence from the MDT showed poor patient satisfaction and engagement with the process before QI changes were implemented. Full results will be available by the time of presentation; currently, an average of 4 patients have attended CTM each week with all sessions finishing on time since implementation of changes.

Patient involvement in care and person-centred care are key to improving engagement and satisfaction with inpatient psychiatric management in forensic settings. Targeted multiple change ideas implemented by the MDT through this QI aim to improve patient satisfaction through enabling increased opportunity to attend weekly CTM, with modifications to the CTM process from key staff. Preliminary results show increased opportunity of patients to attend CTM, increased staff and patient satisfaction, and increased CTM efficiency.

Adolescence represents a critical life stage in which there is rapid physical, cognitive and psychosocial development. It is the time where the patterns and foundations for future health are laid and thus presents a unique opportunity to promote health and subsequently improve life-long well-being and reduce health inequalities. Mental health problems represent the greatest contributors to disease burden for this population and this contribution is forecast to rise. The World Health Organisation state that adolescents and young adults (AYAs) need health services that are supportive, equitable and effective. The project aims to scope out Adolescent care at London North West University Healthcare NHS Trust (LNWH) with a view to improve quality of care for this group of patients.

Quantitative data obtained assessed patterns of presentation to the Emergency department (ED). Qualitative data were obtained through stakeholders Interviews with professionals, adolescent patients and their caregivers. As of January 2022, 113 stakeholders were interviewed. The data obtained informed the creation of the ‘LNWH AYA Manifesto.’ This was converted into a questionnaire for all professionals involved in the care of AYA patients to assess organisational culture around AYA Care.

It was found that AYA care at LNWH lies across a complex cross-sector system. The commonest code for presentation to the ED for those ages 13 to 25 was ‘depressive disorder’. Key themes from stakeholder interviews included: 1) AYAs are not always provided with age-appropriate care 2) Acute Trusts may serve as a catalyst for change for AYA patients and Youth workers may be better placed to connect with them 3) There is a need for an integrated approach to physical and mental health with better relationships needed between the Acute teams and CAMHS. The ‘LNWH AYA Manifesto’ questionnaire found disparate opinions regarding the approach to integrated physical and mental health; of the 34 responses obtained 23.5% reported not feeling confident with recognising and managing mental health and social issues in AYAs and 41.1% believed that physical and mental health problems should be addressed separately by the relevant specialties.

AYA care lies across a complex cross-sector system and thus requires a multifactorial approach to create a culture change towards prioritising this population. One such intervention proposed is the introduction of a Youth Worker outreach model similar to the King's Adolescent Outreach Service as a way to create a shift towards an integrated approach to physical and mental health care.

Childhood and adolescence is a time in which the patterns and foundations for future health are laid. The World Health Organisation advocate for providing opportunities for children and young people (CYP) to meaningfully participate in the design and delivery of services. Co-production, in which professionals and citizens collaborate together in an equal partnership, is recommended as an approach to achieve this and is linked to better community relations. Few co-production models exist that are specific to CYP and address the relevant practical and ethical challenges. We propose a new framework which can be used by organisations wishing to engage in meaningful collaboration with CYP.

To create a model for co-production with consideration of the specific needs of CYP.

The following methodology was used:

1. i) Identification of common themes from ten existing co-production frameworks

2. ii) Detailed analysis of three co-production frameworks with reference to CYP

3. iii) Identification of key issues from critique of the literature

The key themes incorporated into the model using the above methodology were as follows: Purpose, Assets, Capabilities, Reciprocity, Networks and Relationships, Power, Catalysts, Diversity and Inclusion and Safety and Protection. This co-production framework can be used by organisations that wish to meaningfully collaborate with CYP and assess the depth of co-production of their initiatives.

The new model takes into account the socio-cultural challenges that must be considered when co-producing with CYP including power relations, safety and diversity and inclusion. We advocate for the model being tested, validated and further developed ideally with the collaboration of CYP.

Mill Lodge is a 14-bed inpatient neuropsychiatric ward in Leicestershire, UK. The service primarily functions for patients with Huntington's Disease (HD), a disorder that significantly reduces life expectancy. End of Life (EoL) care is necessitated in the inpatient setting. This project therefore aims to optimise EoL care in our specialist HD unit. Specific objectives are to: establish the levels of staff confidence in dealing with EoL care; identify specific areas of EoL care that staff felt could be improved; and to introduce a series of initiatives to optimise EoL care for our patients using a QI framework.

We commenced involvement with the local QI team to develop the project. The first stage of intervention included the planning and delivery of a stakeholder event on EoL care specific to HD with the assistance of regional palliative care colleagues.

As well as our inpatient nursing and medical staff and the palliative care teams, local GPs, district nursing colleagues, speech and language therapists and psychologists attended. The session comprised an educational overview for all colleagues of HD itself and palliation was discussed at length.

The meeting also comprised an open forum where we were able to identify barriers and facilitators to optimal care from all aspects of the assembled MDT.

To date our interactions have revealed that staff confidence in dealing with the different aspects of EoL care was low. This included issues with care-planning; medications; communication with patients and staff; and when to refer for specialist help.

Other processes identified as difficult included paperwork that was not consistent across teams; district nursing colleagues having to liaise with multiple medical team members to ensure continuity of care; and the doses of EoL medications required in this patient group to mitigate involuntary movements that were previously controlled with multiple high-dose oral medications.

Staff without specialist knowledge require support. The efforts made to improve collaboration with external colleagues broke down barriers that were preventing optimal care and allowed all parties to express their opinions and feelings. This allowed us to transparently appraise our current processes and provide guidance on this difficult area.

The journey of optimisation continues, with further practical educational interventions planned, such as syringe-driver training, and efforts to improve shared documentation and enhanced communication and collaborative working between different disciplines.

Optimal, collaborative EoL care from a confident staff-group is possible and a most important part of care for this unique patient group.

This article proposes the need for a theoretical framework that can be applied to underpin the varied idiosyncratic mental health systems.

Bowlby's Attachment Theory defines a set of values that are required for a developing child to acquire a stable base which allow for healthy psychological development into adulthood. These values and behaviours may serve as a caring and holistic framework for people using mental health services.

The outcomes in mental health remain unsatisfactory and services are overall fragmented and increasingly specialised. Ongoing recognition of the inter-related relationship between a person's immediate and social environment and their mental health are frequently overlooked as services become ever stretched in terms of finances, capacity and limited resources including support for staff. The emphasis of treatment is on illness instead of the multifactorial humanity of the individuals using the services. A key outcome of mental health provision is recovery but instead, recovery is compromised by a reductive approach to care that may paradoxically compromise rights, autonomy, confidence and self-belief when people are at their most vulnerable. This creates feelings of mistrust, uncertainty and a limited sense of safety toward services.

Attachment theory takes into account the individual, their experiences, their social world and the significant people in their lives. The principles required for the developing child to develop a secure attachment from a stable base are similar to those required for people experiencing mental illness to facilitate recovery and develop resilience to help manage and reduce episodes of relapse.

Systems that work well, frequently exhibit values underlying models of care that include continuity, consistency, respect, safety, autonomy, human rights, freedom, supportive, trusting relationships and collaboration. The opposite of that seen in what presents as autocratic and risk-averse approaches of many mental health services.

The principles required to enable a child to develop into a psychologically well-adjusted adult are similar to those required when a person is at their most vulnerable. Episodes of mental illness can be a time for reflection and growth, with the right care and therapeutic intervention, illness can also be a time to learn and develop skills for greater resilience in future.

This paper outlines the implications and cultural changes that are required so that the principles of attachment theory can serve as a theoretical framework across mental health services to provide a stable base for people using the services and staff providing the care.

There has been increasing recognition that healthy cultures within NHS organisations are key to delivering high-quality, safe care (King's Fund). A focus towards developing systems which recognise and learn from excellence has been shown to improve services’ safety and contribute to staff's morale (Kelly et al. 2016). In 2019 Secure Services at Devon Partnership NHS Trust (DPT) developed an Excellence reporting system. Once successfully piloted, the intention was to extend to other departments before expanding to the entire Trust. Our aims initially were SMART: for 13 reports per week in Secure services and 8 in Perinatal (a smaller team). As we expanded the aim became qualitative: for a system to be embedded so staff could as readily and instinctively report Excellence as they could an error.

We developed our Theory of Change using Deming's theory of profound knowledge, ran a series of PDSAs, and introduced an Excellence system. We engaged early adopters, sent hand-written cards and shared data widely.

Learning included understanding setting up the system, and the importance of a team rather than an individual holding the system. We took this forward to bring the system to Perinatal. We continued to run PDSAs, then ran monthly trust-wide meetings providing space to learn from other directorates.

Staff were initially excited, reports submitted, feedback good, then a plateau and slump.

Something was stopping the system perpetuating. When staff received timely thanks, and others heard about it, staff would go on to promote excellence. However, this was not possible without sufficient admin resources.

In early 2021 we changed tact and approached the top: we presented data to Directors who recognised the value and agreed to support. We then set about publicising the system, and demonstrating at trust-wide meetings.

By July 2021 we saw 10 reports per week in the Specialist Directorate.

By early 2022 reports were being inputted from staff across all directorates and our monthly meetings began to focus on sharing the learning.

We recognised the system's potential impact on safety and staff morale but struggled to sustain the system and support dwindled when staff were stretched.

After approaching leaders, then allocated resources, it allowed for more success. However, it is not yet fully embedded in our Trust's culture.

A lot of our work happened during COVID-19 and despite challenges there has been a new-found flexibility to innovate, greater ease to negotiate, and instigate change.

The pandemic of the COVID-19 variant caused a near-global lockdown, and the psychological impact of the direct effects of the virus, along with the resulting lockdown periods cannot be overestimated. Referrals made to the Liaison Psychiatry service at Derriford hospital during the 2020 lockdown were audited to better understand effects on patients’ mental health and resulting emergency presentations to services. These data were then used to identify areas for improvement, in order to tailor services to better support the population during recovery from the current lockdown, and for planning for future similar events.

Referrals to the Derriford Liaison Psychiatry service between the 1st and 12th of May 202 were audited, totalling 106 referrals and a subsequent 87 assessments. Quantitative data on patient demographics, presentation, and outcomes was extracted from assessments along with qualitative data on patients’ subjective experiences from the initial lockdown period for thematic analysis. Routine data were used for comparator time periods from 2019, and during the second 2021 lockdown.

Despite a lower number of presentations to ED during the first lockdown, the data demonstrate a higher acuity in presentations with more referrals for admission under section. The lockdown is shown to have particularly affected those with pre-existing psychiatric and physical comorbidity, along with specific patient groups. Thematic analysis confirms this, showing the diverse factors contributing to emergency presentations and demonstrating the increased stress of life in the home under lockdown. Comparisons between the qualitative and quantitative data confirm that patient experiences directly match both the routinely collected data and prior research. The project also revealed a reliance on private and third sector organisations for signposting on from assessments, and highlighted frequent changes to services during lockdown as a source of confusion for both patients and staff.

The scale of impact identified affirms that exploration of the lockdown's contribution to presentation should be routine, particularly for identified at-risk patient groups. Areas frequently highlighted by patients can be used to fully explore the impact of lockdown on presentation during assessment. Patient information for self-referral needs to be regularly updated given frequent changes in service provision. Staff also need to be kept up to date on changing service structure at handover meetings.

Osteoporosis is common amongst elderly patient populations and is associated with significant morbidity and mortality. We aimed to assess whether national clinical guidelines regarding the identification, assessment and management of osteoporosis and fragility fracture risk were being adhered to on a female later life psychiatry ward. We then aimed to improve the detection and treatment of osteoporosis amongst this patient cohort and subsequently conducted a re-audit of adherence to relevant clinical guidelines.

In July 2021, the electronic health records of the 20 most recently discharged patients from a female later life psychiatry ward were reviewed. The proportion of patients who appropriately received FRAX screening, DEXA scanning and pharmacological management of osteoporosis and fragility fracture risk was recorded. The results were compared to standards identified in national clinical guidelines from the National Institute for Health and Care Excellence (NICE) and the National Osteoporosis Guideline Group (NOGG). In addition, the proportion of patients who had FRAX scores communicated to their general practitioners on discharge was recorded. Recommendations were made based on audit findings, and several changes to ward processes were implemented including incorporating fracture risk scoring in a structured ward round template and displaying information posters about osteoporosis in clinical areas. A re-audit was completed in February 2022 using the same methodology as baseline to re-assess adherence to the audit standards.

All included patients were female and aged >65 years, and therefore eligible for consideration of fragility fracture risk according to NICE guidelines. 88% (15/17 patients) of those without pre-existing osteoporosis had FRAX scores calculated during their admission on re-audit compared to 50% (8/16 patients) at baseline. 73% (11/15 patients) had FRAX scores communicated to their GP on discharge at completion of the audit cycle compared to 25% (2/8 patients) at baseline. At completion of the audit cycle 10% (1/10 patients) with intermediate fragility fracture risk received measurement of bone mineral density during admission while 30% (3/10) had this recommended to their GP on discharge. None of the high-risk patients (n = 4) were started on bisphosphonate therapy.

On completion of the audit cycle, we found excellent compliance with national guidelines regarding the identification of osteoporosis and fragility fracture risk, which demonstrates the feasibility of considering this aspect of physical health in the setting of a later-life psychiatry ward. Areas for improvement include the assessment and management of patients identified as having intermediate or high risk of osteoporosis and fragility fractures.

1. To ensure there is documented evidence of discussion about legal aspect of dementia with patients and relatives. 2. To Improve documentation of Financial management by 100% at the end of 3 months. 3.To Improve documentation of LPA and other related legal areas by 70% at the end of 3 months

In Kensington and Chelsea and Westminster Memory services, we are seeing patients with cognitive impairment which can be due to dementia. So, it is really important to discuss and help a person and/or relative with making decision about client's health, welfare or finances. Though each team member discusses about what they did for the same, we identified that it was not reflected in the documentation.

After finalising data collection form, we then performed a retrospective collection of number of documented assessment/discharge report/progress notes within an identified 3-month time period from March to May 2021. Our intervention was Email and MDT remainders, developing patient information video, and structured format to document about legal aspect of dementia like, financial management, Lasting power of Attorney, Court of protection, Advance will, etc. We run PDSA cycles and collected a data at the end of each month to see whether change ideas are helping to improve documentation and whether any modification will require with the plan.

Out of 67 patients record which were reviewed as a baseline data, 39% of them has diagnosis of dementia or Mild Cognitive impairment. Discussion about LPA was recorded in only 16% of the documents. There is no mention of how a person is managing their finances in 30.7 percent of documents. After implementing change ideas, 29 patients who were seen during the month of December were reviewed using the same data collection form. Documentation of discussion about financial management was improved to 93.1%. Documentation of Discussion about how to set up LPA, if a person doesn't have one has been approved from 10.4% to 55.2%. The cycles will continue for month of January and February and data will be assessed and compared at the end February 2022.

Basis on the data available till date, a general improvement in the record keeping of notes was seen. Simple intervention like email reminders, reminder in MDT, structured format for documentation and patient information in visual format can improve the documentation of work. More detailed conclusion will be drawn at the end of 3 months.

Mental health disorders, mostly notably paranoid schizophrenia and personality disorders are commonly seen in patients with a forensic background. Section 37/41, within the Mental Health Act 1983, detains patients who are mentally unwell in hospital for treatment, instead of a prison sentence, with the addition of a community restriction order for public safety. Once stable, patients are discharged by the Ministry of Justice (MoJ) on Section 42, otherwise known as a conditional discharge. This means they can live freely in the community but under a set of conditions they must follow in order to obtain absolute discharge. A leaflet on Section 42 was created after a gap in patient knowledge was identified during consultations. Furthermore, a literature review did not retrieve any relevant results on this topic. The aim of this leaflet was to improve both patient and staff knowledge.

A patient leaflet was created using information from relevant legislation, MoJ official documents, trust resources, the charity MIND UK as well as staff knowledge. A checklist consisting of 12 questions was created to test the patients’ knowledge, with space for additional comments. Care was taken to ensure every question on the checklist had a corresponding answer in the leaflet. Six suitable patients were identified and supported to read the leaflet and a structured interview using the checklist was conducted pre- and post-leaflet. In addition, feedback was sought from staff members of multiple backgrounds. A resource questionnaire was also given to participants to collate feedback. The pre- and post-test answers were compared and given a mark out of 12. A mark was given for answers that were sensible and correct, even if parts were missing for questions that encompassed multiple facts.

All patients were previously on Section 37/41 and now on Section 42. All showed a substantial improvement in knowledge base, with 4/6 patients scoring full marks afterwards. Patient feedback obtained was overall very positive, with many describing it as “useful”, “informative” and “helpful”. Staff feedback was also collated and found to be positive too, with comments including “very informative”, “easy to read” and “clear and precise”.

Our leaflet was well received by both patients and staff. It improved their knowledge base as well as confidence in understanding the medico-legal jargon used in day-to-day practice in the forensic setting. Feedback was overall positive, and the additional patient feedback was encouraging, with many of them wishing for sooner access to similar resources.

The project's aim coincides with NHS England STOMP Pledge signed by BDCFT. To maintain up to date records of children and adolescents with learning disabilities eligible for STOMP reviews, implement planned supervised dose reduction, consider alternatives to psychotropics and maintain an up-to-date record of physical health monitoring for patients on antipsychotic medications according to local Trust guidelines.

The sample consisted of the caseload registered with the CAMHS learning disability Team at BDCFT in December 2021. Each case was reviewed retrospectively through electronic records. Data were collected on a data collection tool designed in Microsoft Excel.

Baseline data about Diagnosis and Psychotropic medications prescribed were recorded. The Antipsychotic prescribing practice was audited against local Trust guidelines as part of the project.

The project was registered and approved by the Trust Audit Team.

The study included 106 cases registered in December 2021.

42 patients (40%) were prescribed psychotropic medication only

10 patients (9%) were prescribed psychotropic medication plus ADHD medication

14 patients (13%) were prescribed ADHD medication only

40 patients (38%) were not prescribed any medication

66 (62%) patients from the sample were prescribed medication.

Medications were divided into, Psychotropics and ADHD medication groups. Each group was assessed against a prescription time standard of either less or more than 12 months.

Antipsychotics were the most frequently prescribed psychotropic medications; 60% of those prescribed psychotropics were on Antipsychotics. A smaller number (31%) on an Anxiolytic, and an even small number (12%) on an Antidepressant. Anticonvulsants were prescribed to 6 in our sample, but all by another service provider (Paediatrics). 20 patients (38%) were on more than one psychotropic medication.

The length of the time was divided into less and more than a year on medication. 20% of patients were on psychotropics for less than 12 months and about 80% for more than 12 months.

As there are local BDCFT guidelines for monitoring patients on Antipsychotics, a summary of compliance against standards was included as an audit in the project.

All 66 patients on medications were deemed eligible for STOMP reviews, and 64 out of them had behavioural support plan in place.

66 patients who had eligibility for STOMP:

1. 1. 35%: Undergoing reduction plan.

2. 2. 35%: Reduction was not deemed suitable.

3. 3. 30%: No review or reduction plan in place

With increasing awareness and reduction of stigma associated with Mental Health issues, referrals to services are increased, pushing specificity of commissioning and therefore declining patients of services when referrals are inadequate. Standards would be improved by better inclusion of information necessary for the Single Point of Access process (SPOA) in the Bolsover Community Mental Health Team (CMHT) to make prompt, effective decisions on allocating care.

A Quality Improvement project in a Mental Health Team was devised to improve standards, and acceptance rate, of appropriate referrals to the Bolsover CMHT from General Practitioners (GPs). This would encourage GPs to refer patients whose mental health difficulties do not meet CMHT thresholds to alternative services. A higher acceptance rate and lower rejection rate would indicate that the proportion of suitable referrals had increased.

Using the Plan, Do, Study, Act (PDSA) model, Driver diagrams were used to create a template with the crucial information necessary for GP referrals to psychiatry/SPOA. Data were collected to check aims of the referral, sufficient information of the presenting complaint, personal & family history, safety concerns, protective factors, comorbidities, medication and substance misuse. The outcome of each referral was recorded and categorised as either Community Psychiatric Nurse Assessment, Outpatient Appointment, Referral Rejected, Referred Elsewhere or No Patient Response.

All referrals in September and October 2021 were analysed to assess whether enough information had been included for each variable. The September and October data were compared to check if the template had been associated with improved quality of referrals.

Pre-template, 17.4% of referrals were accepted, 13.0% received a SPOA assessment, 17.4% were rejected, 39.1% were re-referred elsewhere and 21.8% did not respond to the CMHT. After the template was circulated, 28.0% were accepted, 36.0% received a SPOA assessment, 4% received joint Doctor-SPOA care, 8% had a medication review and 12% were waiting for an MDT decision when data were analysed. The results for SPOA assessment and rejection were statistically significant (p < 0.05), while results for other outcomes were not.

Information on presenting complaint (82.1% to 100%, p < 0.05), personal history (39.3% to 92.3%, p < 0.05) and aims (50% to 88%, p < 0.05) increased, while other information did not change in a statistically significant manner.

The template led to an increased proportion of accepted referrals and a decreased proportion of rejected referrals. However, information on variables did not necessarily improve in the same manner. The template is useful to improve decision-making in SPOA.

To Reduced Mental Health Liaison Team (MHLT) handover time to less than 30 minutes within one month and to improve the quality of handover. The non-medical staff have been part of the team for many years, whilst medical staff have recently changed or are on short rotations. Previous changes have not been well sustained. Much of the initial enthusiasm for this project was coming from the medical staff members. We felt that it was important to fully explore the driving human factors to achieve sustainable buy-in.

The total period of the project was 7 weeks. First two weeks were used for daily baseline data-collection and informal and formal discussions with team members to formulate driver diagram and change ideas. Two “Plan, Do, Study, Act” (PDSA) cycles with two intervention points at week 3 and week 4.

Key human factors identified in the MHLT were burnout and emotional fatigue, core team values (cohesion, flexibility, and camaraderie), and disillusion with authority and imposed change. Contributing factors to burnout and emotional fatigue were long and short-term staff sickness, chronic under-staffing, and systemic changes in the general hospital due to the COVID-19 pandemic. The human factors were used to guide key decisions in methodology and creation of change ideas. These decisions included: Avoidance of surveys and questionnaires (staff request), limiting the total number of changes, any additional administration to be undertaken by medical staff, and avoiding a rigid handover system. Following 2 PDSA cycles, there were improvements in average length of handover from 44 minutes (2-week baseline data) to 30 minutes (4-weeks post second intervention). When compared to the baseline data there were also improvements in the average number of interruptions (7 vs 2), availability of key information (69% vs 92%), allocation of staff member (80% vs 95%) and allocation of review date (83% vs 95%). No difference in the average number of patients for handover discussion between 2-week baseline data (15) and the 5 weeks after (15).

The aims for the Quality Improvement Project were met and a plan has been set to re-audit in both 6 months and 1 years’ time to test sustainability of change. Sudden illness and effects of the COVID-19 pandemic have led to short and long-term staff shortage, contributing to burnout and emotional fatigue. Attention to the unique human factors involved in team dynamics and staff morale can help achieve buy-in and real change.

Medication tasks are an integral part of a junior doctor's job. However, these can often be timely and use hours that could be spent doing other therapeutic work, especially due to the cumbersome nature of SystmOne. Our aim was to review the amount, type, and time spent on medication tasks and evaluate ways in which the system could be made more efficient and time effective, to release doctors to complete other clinical ward activities.

We used prospective data collection, with two ten-day cycles carried out across the 46 bedded adult mental health unit (AMHU). Data were collected by all junior doctors working on the AMHU and every medication task was recorded on a designated document at the time of completion. This included data such as time the task was created, related ward, sender, type of task, amount of medications per task and minutes taken to complete.

During the first ten-day cycle of data collection, we found that collectively we spent 21.5 hours completing medication related tasks. 10 hours were spent ordering medications, seven of which were ordering ward stock. Tasks involving completely re-prescribing the medication for the action to be completed took 12.6 hours. The data showed that 42% of tasks were completed on Mondays.

Following cycle one we discussed the data with the AMHU pharmacy team, ward managers and consultants. Subsequent alterations were made to the stocklists for the wards, ward timings were aligned and a collective tasks system created to reduce duplication of tasks.

During the second cycle of data, in total 16 hours were spent on medication tasks. There was a total of 7.45 hours spent ordering medications, 3.35 hours were ordering ward stock. Re-prescribing tasks took 9.7 hours.

From the results of the second cycle of data we can see the recommendations from cycle one have been effective in reducing the amount of time spent ordering medications by 25.8%. This highlights the importance of regularly updating the stocklists and utilising MDT working to maximise efficiency. We also confirmed that Monday was the heaviest day for tasks, which should be considered for staffing. As 46% of overall time was still spent ordering medications, we presented this data at the medicines management committee. Following this, recommendations have been taken to SystmOne for IT system alterations to improve efficiency of the system and allow junior/trainee doctors to focus more time on the clinical care of patients and learning.

In 2021 The Department of Health published a report into the safer use of medicines in health and justice mental health services, advocating sustainable prescribing as a way of improving patient care and reducing carbon emissions. Improving prescribing behaviour could lead to a reduction of 170,000 kg CO2e per year across England, along with cost savings which contribute to higher value service provision and improved service user experience. We aim to evaluate and improve the prescribing of antipsychotic depot and ‘as required’ (PRN) medication in a male secure unit.

Baseline data were gathered from the patient population in a male secure unit (1 low and 2 medium secure wards, total 50 beds) in December 2021. This included the number of patients prescribed a depot, the type of depot prescribed and whether or not these were administered at the longest evidence-based interval. As part of a wider trust initiative “prn” medication was moved to a fortnightly review cycle to ensure medication was used for as short a duration as necessary. Over a six-week period medication rationale was analysed and discussed with the Responsible Clinician for the service user to optimise prescribing. Data collected following this intervention was compared with baseline results.

The project found that 26 patients in the service were prescribed an antipsychotic depot in December 2021. In this group 17 (65%) were prescribed their medication at the longest evidence-based interval. Of the 9 (35%) that were not, 5 had clinical reasons why a change would not be appropriate at present, however it was agreed this could be considered later in their pathway. Of the remaining service users, two had their dose of medication reduced and their prescribing interval increased. “As needed” (PRN) medications of 15 patients were evaluated; 9 (60%) had medications prescribed which were not in use (4 patients had 3 or more prescribed not used within 2 weeks). Following intervention this reduced to 2 patients, both of which had only 1 PRN medication which required review.

Deprescribing can have a significant impact on patient care and safety and can reduce the environmental impact of a service. This project demonstrated the advantages gained from regular medication reviews and taking into consideration dose and administration interval when prescribing antipsychotic depots. Using protocols for prescribing as needed medications, a structure for reviewing prescriptions, collaboration with patients and utilising patient group directions where appropriate can all aid in improving prescribing sustainability.