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Good practice on Lavender Walk Adolescent Inpatient Unit

5 August 2019

By Siso Moya, Deputy Service Director CAMHS

This article is written to share learning and good practice on how Lavender Walk has achieved low levels of aggression and violence as well as a minimal number of restraints.

Lavender Walk is a new Adolescent Inpatient Unit for North West London Sustainability and Transformation Partnerships (STP) with 12 beds and four day program spaces. It opened in November 2018. The Unit has 40.73 work time equivalent (WTE) staff.

The service is for young people (13 to 18th birthday) with severe and complex mental illnesses and other mental health disorders with physical, social and family variables.

There are also four teaching staff. Each person has an initial assessment of their special educational needs and an individual education plan.

It its first five months the unit has had nine aggression and violence-related incidents.  Six of these incidents were from the same person.

There were also 21 restraints. 11 were in November 2018 and related to one young person who was eventually transferred to a CAMHS Intensive Care Unit.

The Trust’s data suggests that Lavender Walk’s ‘Restraint Rate per 1000 Occupied Bed Days’ is below average against national bench marking.

No. of Restraints

 

Nov 18

 

Dec 18

 

Jan-19

 

Feb-19

 

Mar- 19

Lavender Walk

11

0

2

2

6

We wanted to develop a unit culture so in the initial stages of development, we visited five different adolescent units in London and the South East to learn how different clinical models impact on:

  • patient outcomes
  • engagement in therapy
  • length of stay
  • reduction of violence and aggression
  • low restraint levels
  • re-admission avoidance.

Dialectic Behavioural Therapy (DBT) was identified as a preferred method of therapeutic treatment model for the unit. This was informed by the large proportion of NW London young people diagnosed with emotional dysregulation who are admitted to inpatient units.

Reviews suggest that most violence or aggression episodes in adolescent inpatient units occur after 5pm and in the evening.  Lavender Walk Unit has an evening and weekend therapy timetable developed that is supported by occupational therapists.  Two evenings a week, the Senior Occupational Therapist facilitates these programs alongside unit nurses (in turn upskilling the nursing team.)  The weekend timetable runs from 2pm to 8pm delivered by the nursing staff.

Additionally, there is a weekly out-of-hours Carers Group run by the unit's Senior Family Therapist and a Clinical Nursing Team Lead. This is for families only and young people get to spend time with their families after this session.

The unit operates a ‘No-Touch policy’.  Any physical contact is not permitted unless in life-saving interventions and in restraint episodes, which are the last resort.

All young people sign-up to this agreement on admission. Personal space must be respected at all times. ‘Distancing’ is a proven method that promotes an adaptive form of self-reflection, facilitating emotional processing while reducing emotional and reactivity to negative stimuli and increasing problem-solving behaviour.

Setting out expectations with young people is important.  There are clearly set out and shared consequences to young people when any unsafe behaviours are exhibited.

On admission and after explanation, young people sign a behavioural contract which discourages unsafe behaviour such as:

  • Physically assaulting staff or other young people
  • Bringing dangerous substances/items onto the ward with intent to utilise or distribute
  • Intentional damage of hospital property
  • Inappropriate relationships with other young people
  • Taking photographs of other young people
  • Stealing property.

The unit does not tolerate violence and has an assault management pathway. All incidents of violence including racial abuse, are reported to the police.

Our principles are:

  • Report Report  Report
  • There Are No Excuses
  • We Do Not Tolerate Abuse
  • Let's Make This Environment Safe.

The design of the unit promotes a low stimulus environment; we have multiple protected quiet spaces on the inpatient side and support side which young people are encouraged to use.

This includes a well-equipped sensory room that can be used in late evenings. Our occupational therapists have sourced a number of self-soothing items for young people that they can use in episodes of emotional dysregulation.

We had 12 weeks for staff induction which included common language training such as DBT skills group, motivational interviewing, as well as Prevention Management of Violence and Aggression (PMVA) training.

This facilitated a cohesive staff group who shared a common vision and had trained together prior to the unit accepting its first admission. Regular clinical supervision has facilitated staff retention.