A Note from the Editor Ellie Parker

Seasons greetings and welcome to the very first newsletter from the Quality Network for Older Adults Mental Health Services. Thank you to all the services that have contributed to this edition. We’re very pleased to be putting the spotlight on all the great work you’re doing.

The network has had a busy 2016. We’ve visited 18 services, had 4 accreditation committees, trained 67 peer reviewers and also hosted an Annual Forum in September.

2017 is set to be even busier , as we are set to publish the 4th edition of the network’s

standards and start using the new College Accreditation Registration System. We will also be holding a Special Interest Day in March and we are looking forward to seeing you there.

We would like to take this opportunity to thank our members for all their hard work and contributions over the last year. We hope to continue spreading the word about the benefits of membership beyond the accreditation process and that there is real value in being part of a community of professionals all working together to improve the lives of their patients.

Speech and Language Therapy in Older Adult Services Paul Burdon (Speech and Language Therapist at Woodlands Hospital, Greater Manchester West Mental Health Foundation Trust) discusses how the Speech and Language Therapy Team overcome communication barriers at the hospital.

It is common in older adult’s mental health services that there are multiple barriers to communicating effectively with our service users. This can be due to cognitive

impairment, physical illness or as a direct result of active mental health symptoms. Wards also have multicultural populations and language barriers to communication also need to be considered. It is possible that service users from older generations may have little or no English language, or as part of the progression of conditions such as dementia their second language (English) is much quicker to decline than their native language. Speech and Language Therapists are uniquely placed and skilled to support service users, staff and families to overcome these communication barriers. However, access to [continued on page 2]

1- Speech and Language Therapy in Older Adult Services 3- Pet Therapy 4- Pain and Dementia 5– Art Competition 6– Members of the Accreditation

Committee and Advisory Group 7– Annual Forum and 2017 Dates for the Diary 8- Art Competition and Contact Details

Issue 01 December 2016

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Speech and Language Therapy (SLT) services is usually rare or difficult to come by in older adult mental health services. This sadly increases the risk of patients becoming isolated or agitated, which may contribute to challenging behaviour. Staff in older peoples’ mental health may have become accustomed to SLT input with regards to a service user’s swallowing function, however staff may not have considered how the service could benefit from input around communication. SLT will work with staff, service users and families to gain a full understanding of the service user’s communication skills, in terms of their strengths and barriers, and provide interventions to help minimise or overcome these barriers whether they are a result of cognitive deficits, physical health or active symptoms of mental health. At Woodlands Hospital a small SLT service has been commissioned. The service has been running for approximately 12 months and has been able to provide support for service users to reach their communication potential on the wards working to overcome communication barriers of all types. For example, a patient (K) was admitted to Woodlands Hospital due to a depressive episode. As the lady had only recently moved to England and had no English language skills, this isolated her on the ward. The ward enlisted the support of an interpreter who attended the ward for an hour twice a week at which time the lady was able to express some of her preferences e.g. what she liked for breakfast. Sessions with the interpreter were useful for the ward and allowed her to engage in discussions about her care with her doctor; however it was not possible or economically viable to

have an interpreter on the ward at all times. This meant there were still large amounts of time where she was unable to interact with others on the ward or make requests. This led to long periods of isolation which undoubtedly impacted negatively on her recovery. A referral was made to SLT despite the lady not having a cognitive deficit or an impairment in communication in the traditional sense. Intervention from SLT took two forms: firstly addressing her need to communicate functional needs and secondly her need and human right to social interaction. In order for her to communicate her functional needs she was provided with a picture key ring that had small cards each of which had a picture representing a request, for example drink or phone. In order for staff to be able to perform an informed assessment of her mental state emotions were also added to this (in the form of facial expressions) so that staff could ask K to report how she was feeling. Secondly SLT engaged with K using ‘talking mats’ style conversation (picture based conversation). This was an opportunity for K to engage socially which she appeared to enjoy and was also a useful tool in finding out about her interests in order to inform future attempts to engage her socially. Following this, a care plan was written in order to provide staff with confidence and ideas to engage with her socially on the ward. These suggestions were based on her interests some of which were games which could be played without the need for language such as dominos, and others used everyday materials such as looking at cricket scores (one of her interests). Staff were also able to use the picture based conversation technique to talk about a variety of topics. This intervention and collaborative working of SLT as part of the multi-disciplinary team demonstrates how communication barriers can be overcome and have not only improved the patient’s ability to get her functional needs met but has also improved her ability to engage socially with others which has a positive impact on her mental health and recovery.

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Introduction People living with dementia are at increased risk of having their pain under assessed and undertreated (Zwakhalen et al 2009). Reasons for this include dementia-related factors such as loss of communication ability and pain being manifested in the form of behaviour, e.g. agitation. Health professional–related factors such as reduced knowledge of the ways pain can manifest in dementia and a lack of knowledge regarding pain management also contribute (McAuliffe et al 2012). Historically on the dementia inpatient assessment wards in the trust, the nursing staff have undertaken a pain assessment within the first week of admission. However, there was a concern within the multidisciplinary teams that this approach was failing to adequately assess and address pain. A more in-depth approach was required and a workshop, supported by a Pain Specialist Nurse from the University of Manchester, was held to address this. At this workshop staff reflected that there were developmental needs within the teams in relation to understanding and differentiating between pain and dementia related behaviours and the use of pharmacological and non-pharmacological pain management strategies to manage pain. At the workshop staff also reviewed 9 dementia pain assessment tools and concluded they all had limitations. None of the pain assessment tools available were developed in dementia inpatient NHS wards and the majority did not offer any decision making guidance.

The Project A Pain and Dementia Project stemmed from this workshop. This was initially a nine-month project which was funded through the trust’s ‘Dragon’s Den’, and was guided by a multidisciplinary steering group. The project had two main objectives: To undertake a comprehensive review

of dementia specific pain assessment tools. The findings of this would be used to develop a GMW dementia specific pain assessment and decision guidance tool.

To develop a programme of training for staff which will include; obtaining detailed pain histories from patients’ families, assessing pain by using the developed assessment and decision making tool, increasing understanding on how pain can affect behaviour in advanced dementia, improving knowledge on pharmacological and non -pharmacological approaches to pain management.

A qualified nurse was seconded for 1 day per week for 9 months as the project lead. This gave ring fenced time to lead the review, assessment tool development and facilitate the training and development of staff. What was undertaken within the project? An extensive literature review A baseline measurement of the nursing

and medical teams’ current knowledge and skills, gathered using a staff questionnaire

A snapshot analysis of pain prescribing and analgesic administration through an audit of the patient prescription records

The production of an 'assessment and decision making tool' that would be marketed as a GMW tool. Practitioners across the services were then asked to pilot the tool and it was amended from feedback received.

The results of this work found that as is reflected from the extensive literature review, the assessment and management of pain in dementia remains challenging for our

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clinical staff. Our staff have had very little formal training on pain assessment and management. There was a keenness amongst clinical staff to develop their practice and improve patient care. What does the future hold for the project? The secondment of the project lead has now reached an end in November 2016, the training programme is ready to deliver and will commence in January 2017. The steering

group will continue to meet within 2017 to look at ongoing development and sustaining the progress made over the last 9 months.

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Annual Forum 2016

In September the Older Adults network hosted it’s first Annual Forum. We were lucky enough to have a number of interesting presentations spanning psychiatry, psychology, support for carers and improving how we capture patients experiences on accreditation visits. For those who couldn’t attend, we’ve included a summary of what was presented on the day. Our keynote speech was delivered by Dr James Warner, former chair of the Faculty of Older Age Psychiatry at the Royal College of Psychiatrists. James discussed the history and current picture of older adult services. Including the potential loss of the older age speciality as some services become ageless. He gave a compulsive argument for why the speciality is still very much needed, and provided insight into how the faculty planned to respond to the trend. Dr Natasha Lord and Dr Sarah Dexter-Smith, both Clinical Psychologists delivered an interesting workshop aimed at giving members a better understanding of the role of a clinical psychologist for Older People’s inpatient services and looks at some the myths surrounding what Psychologists on an inpatient ward do. We were also delighted to have Nicci Gerrard—co-founder of John’s Campaign—share with us how this campaign, prompted by the needs of dementia patients and their family carers in acute hospitals and general wards, could be translated into the inpatient mental health setting. Behind the campaign

is the belief that carers should be welcome to stay with their loved one in hospital, and should be welcomed to work in partnership with professionals as they have a wealth of knowledge about their relative. Lastly, our the network team gave a presentation on the work an American Medical student, Azza Bakkar, had conducted with the network in Summer 2016. Due to the nature of illness on the older people mental health wards, it is not always possible to collect comments and views from patients which, apart from being crucial in determining the accreditation status of a service, are also essential in determining the quality of care provided by the ward. The network team had identified a need for a new tool that would allow us to incorporate a measure of patient experience. During the six weeks work placement, Azza compiled an extensive literature review which formed the basis of the ‘Bakkar Observation Tool’ also known as ‘The BOT’. The BOT will be incorporated into the 4th Edition of Older Adult standards which are due to be published st the start of 2017. 100% of attendees reported back to us that they found the forum good or excellent overall. Feedback included “Valued forum to share good practice” and “Enjoyed the day - informative and educational. Hope to implement many aspects and possibly seek accreditation”. We have plans for our events in 2017 to be even bigger and better, and we look forward to seeing you all there.

Dates for the Diary 2017

Peer reviewer training day 6 February 2017

Special Interest Day

28 March 2017

Peer reviewer training day 13 September 2017

Annual Forum 17 October 2016

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www.rcpsych.ac.uk/qnoamhs

Art Competition Honourable Mentions

The standard for the art competition was so high we had to include some of the other entries! Submissions are from Cherwell Ward, Oxford Health NHS Foundation Trust [top right, bottom right and top left] and Clock View Hospital, Mersey Care NHS Trust [bottom left].

Contact the Older Adults Quality Network Team: Sarah Paget Programme Manager Sarah.Paget@rcpsych.ac.uk 020 3701 2675 Hannah Bolger Deputy Programme Manager Hannah.Bolger@rcpsych.ac.uk 020 3701 2679 Eleanor Parker Project Worker Eleanor.Parker@rcpsych.ac.uk 020 3701 2677