APPENDIX C: EXAMPLES OF GOOD PRACTICE LSU Cycle 2 Good Practice.pdf · APPENDIX C: EXAMPLES OF GOOD...

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APPENDIX C: EXAMPLES OF GOOD PRACTICE

A: Model of Care

1. Admission

Bowman Centre

All patients have a home area care coordinator who is involved in facilitating ongoing links with home area services and the patients care pathway.

Michaela Burt

01208 251 439 [email protected]

Wickham Unit

The admission process was highlighted especially the development and establishment of a service users buddy system that includes set tea times to meet up when transferring to different wards.

Julie Somerville


Vista Healthcare

The pre-admission visit and information provided was praised by the patients spoken with on the day.

Susan Clark 01252 845 826 [email protected]

2. Recovery

All Saints Hospital

An example of the service’s innovation and commitment to patient recovery is that My Shared Pathway has been colour coded for better understanding, and it has been implemented as a theme throughout the whole of the hospital

Wendy Connolly


All Saints Hospital

Despite no accredited programmes of therapy for deaf forensic patients, the service has completed research and created a programme adapted for the patient type. The peer-review team were impressed with the amount of work that has gone into preparing patients’ for offence specific work, adapting therapies, and the future plans such as implementing group work and ‘coping boards’ for both staff and patients.

Wendy Connolly


Allington and Tarentfort

The Recovery group was praised, especially the innovative exercise where patients were asked to complete the biography of an imaginary patient, and put them through the care pathway, to teach patients about the processes.

Dr Anthony Fernando

01322 622222 [email protected]

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Cooking on a budget, and groups on life after forensic services, show how the service is committed to patient recovery, and ensuring they build the skills and community links needed for discharge.

Dr Anthony Fernando


Alpha Hospital Sheffield

It is praiseworthy that patients are very much involved in and take ownership of their care plans, from the initial stages of inviting people to their meetings to the later stages of report writing.

Kirsty Fishburn


Annesley House

The service has a recovery focused practice, which makes the recovery pathway more meaningful to the patients by breaking down the different elements into more understandable portions. By way of illustration, it was reported that the patients ran informative sessions, for instance on stigma, personality disorder and Asperger’s Syndrome, to develop their understanding of these issues.

Wendy Khan 01623 727 900 [email protected]

Arbury Court The use of My Shared Pathway in care planning, especially the use of milestones and timelines, was commended.

Sue Taylor 01925 400 600 [email protected]

Ash Ward

There is an excellent gym facility, and activities such as cooking, and visits from MIND who provides projects such as reflexology. The service was also visited recently by a Laughing Therapist which was enjoyed by both staff and patients, and the service hope to incorporate this type of therapy into the service in the future.

Colin Reynolds


Ashley House

The Ashley House team have managed to develop excellent community links and voluntary vocational opportunities, with around 80 per cent of patient activity being within the community.

Aimee Dunn 01630 674800 [email protected]

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Ashley House

Ashley House have a full-time teacher, who delivers a rolling programme on a 1:1 basis with patients, for basic numeracy and literacy, and for those who are uninterested in education, the teacher implements creative ways to provide education, such as educational days out.


Bracton Centre

The peer-review team were also impressed with the detailed therapeutic timetable that had been professionally printed and noted that the design made it very engaging

Lisa Dakin 01322 294 300 [email protected]

Burston House

The excellent facilities and activities available at the Life Skills and Education and Vocational Opportunities Service (LEVOS) was highlighted. This consisted of a training kitchen, laundry facilities, a games room, a kiln, a fitness room, a health and beauty salon, a wood workshop, an art room, a garden and a classroom/computer room.

Deborah Bullman


Burston House

The patients reported feeling supported in understanding their recovery pathway with picture boards in their bedrooms and individualised portfolios illustrating the process in a more simplistic and meaningful way. Patients stated that they were able to track their own progress easily.

Deborah Bullman


Cygnet Hospital Godden Green

One particularly notable area of patient involvement was the map on the ward wall which displayed information about the local area to encourage patients to explore the local community. The map included bus timetables, a map of the local area, local resources and possible activities.

Petra Nkomo 1732763491 [email protected]

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Cygnet Hospital Godden Green

The service promotes a philosophy of individualised care, which was particularly evident throughout the tour of the unit. By way of illustration, a three tier system was observed by the team whereby patients are moved through the ward depending on their stage of recovery. This practice allows the patient to better comprehend their treatment and pathway to improved mental health.

Petra Nkomo 1732763491 [email protected]

Cygnet Hospital Kewstoke

The degree of focus on recovery at the service is also highlighted by the integration of a Drug and Alcohol team on the ward, with female specific drug and alcohol groups and individual work. The service trains all staff within this area which is an example of good practice at the service.

Barry O’Driscoll 01934 42898 [email protected]

Cygnet Hospital Stevenage

One of the main areas of achievement for the service was the cafe at the unit. This area is run by service users and provides a great opportunity for a vocational placement.

Colin Doyle 01438 342 942 [email protected]

Cygnet Wing Blackheath

The outcome measures newsletter was particularly highlighted, as it asks patients routine outcome measures, such as on their quality of life, HoNOS and feelings, and then a report is produced for everyone to see.

Michelle McWilliam



The peer-review team particularly praised the service for its innovative random drugs tests, where the service play bingo with the patient’s room numbers, and whoever’s room number is selected has to complete a drugs test. This involves patients in this process, and also makes it fair.

Michelle McWilliam


Ellesmere House

The peer-review team commended the ward based decoration representing My Shared Pathway as a road map to recovery.

Dr Jayanth Srinivas


Eric Shepherd Unit

The service has a range of work experience placements with the RSPCA, Big Well garden centre and links with the college for City and Guilds courses.

Ian Tearle 01923 682062 [email protected]

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Farmfield Hospital

the peer-review team commented that it was a strength that there are NA and AA sessions taking place within the unit, as this can be easily transferred to the community.

Mark Watts 01293 787500 [email protected]

Forest Lodge

The peer-review team commended the service for developing with the progression of technology, by allowing patients to have personal mobile smart phones, after completing a risk assessment. By doing so, the service is ensuring that patients are kept up-to-date with technology, and thus, preventing patients from feeling alienated on discharge.

Ajay Pawar 0114 271 6051 [email protected]

Foxhall House

The peer-review team were impressed that after 28 days of admission, patients receive their first CPA, and this is then repeated every 3 months as standard. My Shared Pathway has also been integrated into the service, concentrating on patients’ strengths and personal goals, and relational security is also included in care plans

Brian Davis 01473 329 193 [email protected]

Francis Willis Unit

A number of iPad’s have recently been commissioned to be used as a tool for skill development, as the service are keen to provide technological education to patients as many can find new technology quite daunting. Another example of positive risk-taking was the ‘pint pass’ which encourages patients to socialise with each other, staff members and the local community. Both staff and patients reported that this process, which issues one pass per visit, facilitated the transition back into the community.

Jocelyne White

01522 573625/3 [email protected]

Gerry Simon Clinic

Patients also noted that they felt very much involved in aspects of their care, including representation at patient council meetings, ownership of their CPA meetings as well as high level of engagement in daily activities. It is noteworthy that patients feel listened to and that prompt action is taken following on from comments provided.

Dr Joseph Vella


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Hellesdon

Laptops are available for each ward for supervised patient use and the service are planning to use these as a way of further involving patients in their own care planning.

Lorraine Concannon


Huntercombe Hospital Norwich

The ‘Life Star’ on the wall of Gresham 1 and 2 was highlighted as a strength. The large chart explaining recovery helps to engage patients, especially because it is personalised with lots of pictures and patient work. The peer-review team commended the use of the large recovery tree designs in different parts of the service.

Neil West 01603 277 100 [email protected]

Langdon Hospital

The team found the employment of Vocational Rehab Workers (VR) and Sports Workers for six days a week to be commendable, as well as the employment of an onsite Physiotherapist.

Julie Donaghue


Meadow View

The innovative use of space for patients to learn maintenance skills, with doors fixed to a wall, so that patients could learn to strip, paint and polish them. The service also have plans in place to extend this further so that patients can learn basic electrics, and additionally, use their 10 acre grounds to develop activities such as a crazy golf course and horticulture.

Stuart Docherty


Newton Lodge

The use of mobile phones on the ward was seen as a positive move and was highly commended by the peer-review team. Patients are able to access personal phones depending on risk management.

Catherine Eaves


North London Forensic Services

There are full therapy timetables on each ward to allow full engagement in patient recovery. This includes, work experience, ward employment and self-catering. In addition the Kingswood Centre was noted to be an asset to the care provided by the service, including a wide range of therapeutic and recreational activities, such as the gym, horticulture and music.

Sara Henley 020 8375 2711 [email protected]

Northgate Hospital

There is a 72hrs CPA at the unit and it was reported to bring all the relevant people together early on in the care of an individual.

Shirley Wakefield


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Oxford Clinic

The unit has developed excellent community links providing real work opportunities such as working at the shop and the gardening project. It is also commendable that the service provides a range of educational opportunities to patients.

Jude Deacon 01908 243056 [email protected]

Oaktree Manor

There is a specific Occupational Therapy Centre (OTC) that runs sessions seven days a week and provides a mixture of therapies, activity sessions, work opportunities and education sessions.

Beatrice Nyamande


Rathbone LSU

Wavertree Street' is a corridor between the two wards mimicking a typical high street, that hosts an ADL kitchen with gas and electric cookers, a gym, laundrette, art rooms, computer area and red telephone box.

Sara Finlayson


Saddlebridge Recovery Centre and Alderley Unit

Groups and individual work have been developed that assist in the transition from being in a service to the community, such as road safety groups. Health promotion is incorporated into daily activities like cooking, and patients have access to gyms both on an offsite.

Dave Jones 01625 862 400 [email protected]

St. John's House

There is an array of therapeutic and leisure activities available to patients, incorporating education, life skills, psychology and health promotion. These activities are collectively planned by staff and patients, and laid out on individual, uncomplicated timetables. Additionally, patients have been selling their crafts, such as cards, by running a stall on site. This has enabled the patients involved to enhance a range of skills, and there are plans to progress this further with the induction of pottery.

Rosario O’Connell 1379643334 [email protected]

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St. Andrew’s Nottingham

The service has a patient peer-review system in order to transform patient recovery into a more meaningful process. This practice acts as a means for patients to help and guide each other through their recovery, enabling themselves and others to progress positively. The system was developed as part of the therapeutic community practices taking place within parts of the service.

Elizabeth McKeever


St. Mary's Hospital

The peer-review team praised the work that has been done to adapt the My Shared Pathway workbooks to the patient group at St Mary’s and to embed this way of working in the service.

Alan Malin 01925423300 Ext 238/265 [email protected]

The Ansel Clinic

The service has good links with the community and provides access to a varied programme, from college courses and voluntary work to fishing and daytrips. The service has collaborated with the local council to hire bicycles for the patient group which remain onsite. Upon risk assessment, the patients can use these to travel to their off-site recreational and occupational commitments, encouraging independence.

Richard Idle 0115 9457070 [email protected]

The Dene

The timetable is flexible, and tailored to individual needs in consultation with patients. The service has excellent links with local charities and organisations, which give patients vocational opportunities in the community to assist in recovery.

Kim Hill 01444 231000 [email protected]

The Spinney

The Spinney was praised for the self-medicated programme. This is made up of four stages that patients work through and patients reported having a lockable cabinet within their bedrooms to self manage medication. This programme has seen positive results by the unit

Dawn Brennan


Thornford Park Hospital

After the CPA meetings, the service users receive a pack of the CPA reports and an evaluation form to mark down how involved they were within the process. The peer-review team also commended the appointment of a CPA coordinator.

Dawn Jefferies


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Wells Road

By way of illustration, the Nottingham Recovery College campus was established on the same site as Wells Road in September 2013 and offers recovery focussed courses. The prospectus includes courses in anger management, anxiety management and building self-confidence. The OT also has many links in the local community for skills-based work placements, volunteering opportunities and college courses.

Jeremy Resnick


Woodlands House

The number of activities and the variety of sessions available for patients was highlighted as a strength. It was reported that the timetable is well structured and reviewed every 12 weeks with feedback from patients.

Jude Deacon 0845 219 1236 [email protected]

3. Physical Healthcare

Ash Ward

The employment of a Healthy Lifestyles Officer ensures that the health needs of patients are met, with regular gym sessions, physical health checks, and healthy eating groups.

Colin Reynolds


Chichester Centre

The service have just introduced a dedicated primary health service consisting of a GP and Practice Nurses. Patient’s medical needs are also met by on-site medical staff with access to tertiary referrals when required.

Nick Badoorally


Clifton House It was commended that the service held a world oral health day to increase dental hygiene awareness.

Beverley Hunter


Eaglestone View

The review team praised the “Lunch and Learn” weekly meeting; patient food choices are planned and patients are able to prepare the ward meal each week. It was also commended by the peer-review team that the service liaises with local take-away outlets in order to identify healthier options available on their menus to inform patient choice on take-away nights.

Malcolm Campbell


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Forest Lodge

The fully equipped gym, along with the employment of an external gym instructor, provides patients with groups like Tai Chi, yoga and meditation, as well as health promotion through fitness.

Ajay Pawar 0114 271 6051 [email protected]

Hollins Park Hospital

The peer-review team were impressed with the design of the clinic rooms; inside the door is a counter which echoes the design of a community pharmacy and increases privacy for conversations around medication.

Sue Lee 01925 664 108 [email protected]

Kneesworth House Hospital

The service has developed physical healthcare passports that records patients’ physical healthcare needs and allows monitoring of healthcare.

Linda Ram 01763 255700 [email protected]

Llanarth Court Before a CPA, patients receive a full health check, have access to a healthy eating group, and the service has a healthy eating policy.

Dr Phil Huckle


Meadow View

The service has a member of the Occupational Therapy team trained as a gym instructor, who writes programmes for patients. There are two gym sessions a day, but patients can also have access at any point, as long as they have a written programme.

Stuart Docherty


Ridgeway

The physical healthcare suite at the service was highly impressive, consisting of reception staff and separate GP and Dental areas. There are also plans to increase the staffing of the physical healthcare area, including the recruitment of a modern matron to oversee this facility.

Stephen Godwin


St. Andrew’s Birmingham

The dietician meets with patients to discuss the limitations and budget for food, so that patients are fully involved with the service, and with the food received. Additionally, the traffic light system allows patients to see instantly which foods are healthy, and is an innovative way of promoting patients health.

Imogen Mortiboys


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St. Ann’s Hospital

Patients are able to access physical health checks every 3 months and weekly observations, and the service also has a Junior Duty Doctor on-site. The service has a guest speaker once a week that covers topics such as health promotion, which is excellent.

David Porter 01202 708881 [email protected]

Southfield

It was also noted that the service have developed working protocols with the local GP and dental services ensuring that all patients are registered and that patient’s physical healthcare needs are also addressed.

Luke Birmingham


Wolfson House

There were innovative initiatives advertised for patients, such as receiving a £5 bonus for attending the gym at least 8 times a month, to promote physical health. The Recovery Club House, a peer-support group for substance abuse, was highly praised by the peer-review team.

Deborah Bull 020 8510 2003/4/5 [email protected]

4. Discharge

Bowman Centre

There are high levels of involvement from home area services especially when a patient is progressing towards discharge. The service has a pre-discharge system in place where patients visit for progressively longer stays in home areas, from 1 night to 2 weeks, before being discharged.

Michaela Burt


Burston House

There is a pathway that has been developed across the wards. New admissions start their pathway on the Kestrel ward which is divided into three areas; red, amber and green, that indicate risk. When the patient is ready to progress they can move onto the Eagle ward upon signing a residential agreement where greater facilities are available, and the final stage for patients to achieve is the Rectory ward, encouraging them to be more independent and developing skill sets for when they move into the community.

Deborah Bullman


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Cygnet Hospital Harrow

The review team were impressed with links the service have forged with the local community in terms of leisure, education and employment as well as the wider links with home area community teams.

Navin Ramgolam



The peer-review team particularly praised the My Shared Pathway drop-in sessions available to patients. Additionally, to build on skills ready for discharge, there are sessions that aid patients to build confidence, improve communication skills, and tackle stigma.

Michelle McWilliam


Foxhall House

The community team are very much part of the inpatient team, to support patients with the transition from secure service. Some patients are able to step-down to a Recovery Service, and become more exposed to the community and independent living. Once patients are discharged, they are still able to refer back to Foxhall House for support and their services once in the community.

Brian Davis 01473 329 193 [email protected]

Wells Road

Wells Road have recently introduced a new step-down facility, Prospect House. The unit is designed to support patients in their transition and to help them adapt to a less supported environment. This facility is a great resource in reducing the average patient length of stay and for allowing patients to take responsibility for their own recovery.

Jeremy Resnick


B: Safe Therapeutic Environment

1. Physical

Alpha Hospital Bury

Employment of clinically trained staff to security positions was praised, as there was a greater understanding of the patient groups when reviewing the physical security of each ward environment and that of the service as a whole.

Mark Simon 0161 7627200 [email protected];

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Amber Lodge

The team highlighted the biometric key Trakka as an area of good practice. Staff access secure keys by the use of their fingerprint, and new staff are inducted onto this system on their first day at the service. The secure doors within the ward are also locked using the biometric system.

Louisa Endersby


Beech Ward

Particularly the control of staff keys which are accounted for 3 times a day, and are alarmed so that if they are taken out of the secure area, the staff member or reception staff are alerted.

Janice Lepori 01923 850 501 [email protected]

Clifton House

A large investment has taken place within the service to ensure that all ligature points have been removed, and windows have been updated to prohibits the passage of contraband while allowing plenty of fresh air into the rooms.

Beverley Hunter


Newsam Centre

It was clear to the peer-review team that there have been challenges for the service in relation to privacy and dignity in the garden and courtyard areas, but the staff have put a lot of work into developing the perimeter to ensure that these areas are upheld in a way that does not increase risk. For instance, a privacy screen has been added to the areas where the fence boundaries public areas.

Mark Dodd 01138 556 467 [email protected]

Sutton’s Manor

The Morse Key Watchman system is a very robust method of key management and it is praised that this system inhibits staff from leaving the secure area with their keys.

Alan Jackson 01708 687398 [email protected]

2. Relational

All Saints Hospital

There is a pop-up shop, which is a business enterprise, that has given patients the opportunity to develop work skills, independence and responsibility. Further paid in-house work opportunities are available, such as recycling assistant and catering assistant, and these can be applied for every 3 months.

Wendy Connolly


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Amber Lodge

The review team were impressed with the provisions in place for work opportunities. It was observed that there is a horticulture and gardening scheme on site called ‘The Wall Garden’ where patients can work in the gardens and in the small shop that serve both the service and the public. In addition to this resource, there are also links with other schemes, such as: conservation projects, and a stable that provides horse riding to those with disabilities.

Louisa Endersby


Arbury Court

There are high levels of nursing engagement and it was noted that this had lead to a firm understanding of the relational security issues affecting the client group and a calm and positive atmosphere throughout the service.

Sue Taylor 01925 400 600 [email protected]

Ash Ward

The service held a dedicated day to relational security to improve staff knowledge, and that the ward’s Psychologist and Ward Managers provide See, Think, Act training.

Colin Reynolds


Chichester Centre

Relational security is discussed regularly in the programme of reflective practice sessions which are facilitated by staff external to the ward. There are also weekly therapy planning sessions and referrals meetings which staff can attend where relational security is also discussed.

Nick Badoorally


Cygnet Hospital Derby

The service has fully embedded the ethos of See, Think, Act and Relational Security, and patient and staff spoke of the positive therapeutic relationships throughout the service. Patients in particular reported feeling heard not just listened to.

Guy Bannister


Edenfield Centre

The Edenfield Centre hosted a Relational Security week with a number of sessions and information provided for staff to gain a deeper understanding of relational security. It is also commended that the service are currently reviewing relational security knowledge to analyse the impact of the week and ways of further developing it next year.

John Walker 0161 772 3680 [email protected]

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Gerry Simon Clinic

The links that the service have formed with local colleges were noted to be excellent; it was noted that Walsall College do regular sessions within the unit and patients are highly engaged in this programme.

Dr Joseph Vella


Hollins Park Hospital

The peer-review team commended the shop and catering contracts that the service has developed with the main hospital site. The unit have ensured that the small shop in the main hospital will be run by patients at Hollins Park and have made a similar contract with the catering department to ensure that at least one voluntary opportunity is available. In addition to this, patients also have the access to roles in the gardening centre, dog walking and interviewing for new staff.

Sue Lee 01925 664 108 [email protected]


The team commended the use of pet therapy at the service, sandwich making for the Salvation Army and the shop. Very positive feedback was also received in relation to the evening sessions that are held at the service


Oaktree Manor Links to external work opportunities at a Nature Reserve and a cafe ran by and for people with learning disabilities was also noted as a strength

Beatrice Nyamande


Oaktree Manor

Oaktree Manor have devised an electronic relational security tool for staff to accurately measure the ‘temperature’ of the ward. Staff measure a number of standards as green, amber or red and then produce action plans to rectify any issues and areas in need of improvement.

Beatrice Nyamande


Southview Staff reported that they receive regular clinical and group supervision and have access to reflective practice

Jonathon Lynch


Southview It was observed that the service have a work opportunities board to advertise any patient vacancies

Jonathon Lynch


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St. Andrew’s Essex

A lot of work has gone in to developing the CPA process at the service; patients are able to chair CPA meetings, receive a checklist prior to the CPA to ensure that they are aware of the CPA standards, and reported that there has been a great improvement to the process. The service has redeveloped the CPA reports so that there is one report representing all disciplines and that is in line with the 8 domains of My Shared Pathway. This allows discussions to be focused on moving forward.

Ron Gutu 01268 723 800 [email protected]

St. John's House

The service has an onsite teacher experienced in both learning disabilities and forensics, who delivers both group and individual work. Patients are able to work towards qualifications, and the teacher is also able to complete basic dyslexia tests. The importance of education at the service is apparent, with nursing staff also integrating education into daily life activities, such as mathematics within cooking and reading sessions.


St. John's House

There are a number of vocational opportunities both on and off site. There are opportunities such as cleaning, stock taking, chicken care and carpentry assistants. These opportunities are treated as any other job, with an application form, interview and small wage.


St. Magnus

The activity programme is very patient focused; each patient has an individualised timetable and there are a variety of sessions available. Specific programmes of treatment are offered where required and the Occupational Therapy department provide support with literacy, numeracy and IT where appropriate. The ward programme is also well organised and clearly displayed.

Dr Patrick O’Sullivan


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Vista Healthcare

The morning meetings held on each ward daily also received praise for their help in planning out the daily activities for each patient and for the ward as a whole.

Susan Clark 01252 845 826 [email protected]

Wells Road A staff rotation system was also in operation to encourage staff to experience working in different areas of the service and learn new skills.

Jeremy Resnick


3. Procedural

Alpha Hospital Woking

There is a thorough complaints procedures in place and the appointment of a Complaints Manager who completes monthly analysis of trends is an area of good practice.

Ruth Mabika 01483 795 100 [email protected]

Cygnet Hospital Derby

The review team were highly impressed by the work which has been done to build relationships with the local police liaison service and the ongoing work the service are doing with MAPPA and the DPMU.

Guy Bannister


Northgate Hospital

the peer-review team were impressed with the patient’s knowledge and awareness of service procedures and structures, for example knowledge about accessing advocacy services, their rights and the complaints procedure.

Shirley Wakefield


C: Service Environment

Beech Ward

The multi-faith room was also a facility commended by the peer-review team, as it had a range of religious paraphernalia, which included a Quilba arrow and flags of different countries.

Janice Lepori 01923 850 501 [email protected]

Bowman Centre

The music room at the service was commended for its inclusive nature and for the range of facilities appropriate and appealing to both older and younger patients and differing skill levels. These include DJ mixing tables to gramophones with vinyl records.

Michaela Burt


Cheswold Park Hospital

Particular praise was given in relation to The Sanctuary, which serves as the multi-faith room with proper church pews and the team felt that the room exuded a quiet spiritual space.

David Williams


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Edward House

it has made good use of the outside space available and has a good sized courtyard for each ward as well as a courtyard attached to the activities corridor which can also be accessed during visits.

Ian Carr 01245 315 850 [email protected]

Edward House

The peer-review team noted the fittings and furnishings at the service to be of high quality. It was noted that while these were to low secure specification, the fittings and furnishings that had been installed made the environment feel non clinical and more domestic in nature.

Ian Carr 01245 315 850 [email protected]

Eric Shepherd Unit

The unit has developed an excellent child visiting room with toys for a range of child ages. In particular the disabled en-suite attached to the child visiting room was praised by the peer-review team.


Hazelwood House

The mobile phone scheme which grants graded access to patients depending on their risk and behaviour. It was reported that there were three levels of access; ranging from stage one where the patient can use their mobile phone in the private telephone room during a specified timeframe to being granted access in their bedrooms between the hours of 9am and 10pm. The patients were keen on this practice and reported it was preferable over the phone card system.

Palmer Chinosengwa


Kemple View

The multi faith room at the service was of a high standard and the storage that had been developed on site to store all religious paraphernalia, including symbols and a checklist for each religion, was commended.

Mags Gallagher


Kemple View

The team commended the library on site in particular the rotation of books, as this allows new material for patients who use it frequently. The shelves within the library were noted to be made by patients on site.

Mags Gallagher


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North London Forensic Services

The flats on the low secure were commended by the peer-review team in terms of assisting patient progression along the pathway. The peer-review team were impressed by the fact that a patient had been able to cook dinner for his family in the flats.

Sara Henley 020 8375 2711 [email protected]

Rathbone LSU

The child visiting facilities were excellent, and this is supported by the service gaining a Jelly baby award for providing excellent facilities for children. The child visiting room includes a range of toys for all ages in a comfortable room.

Sara Finlayson


River House River House was praised for the Chapel on the grounds which many of the patients use, and have access to a Priest within this facility.

Sam Antwi-Marful



The peer-review team particularly praised the patient murals around Alderly ward, especially the one for My Shared Pathway.



The general environment of the LSU wards was particularly noted to be excellent by the peer-review team. The wards were bright, and personalised with wall stickers and decorations. The Tree of Acknowledgement on Moor Green ward was a feature especially commended, and the peer-review team enjoyed reading the positive comments patients had posted on it.

Imogen Mortiboys


The Humber Centre

Darley House has access to an excellent family visiting room. The room is bright, large, and is able to be cleaned easily to maintain hygiene. There is a one-way mirror so staff can oversee visits, and there has also been CCTV installed.

Dave King 01482 336200 [email protected]

D: Workforce

All Saints Hospital

There are always deaf staff on the ward, and the service employ staff both with and without experience of deaf services who can also bring new skills to the team

Wendy Connolly


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Some of the staff at the service have recently completed a teaching course, to be able to deliver information to patients in an effective manner, and they felt it had opened their eyes to teaching.

Dr Anthony Fernando


Alpha Hospital Woking

There is a Teacher who works for the service and is available on site at all times, and in addition there is a full time Clinical Trainer who is able to assess training needs and ensures that all mandatory training sessions are completed.

Ruth Mabika 01483 795 100 [email protected]

Annesley House

Frontline staff praised the revised supervision system which provided a more structured and consistent provision. An off-ward staff member solely manages the supervision for all staff at the service and the staff reported that this was going well.


Bowman Centre

It was also praised that the service has a social inclusion worker as part of the MDT, who works with the patient group to establish links with the community in terms of real work opportunities and access to education.

Michaela Burt


Burston House

The peer-review team commended the training structure for all staff. The service plans training in blocks to ensure all staff members can access the training they require and with minimal disruption to their duties. There is also team training set aside for one day every month to ensure staff are up-to-date on relevant topics.

Deborah Bullman


Calderstones West Drive and Maplewood

SALT team use iPad's to make assessments, which works well with LD patients.

Fiona Gibson, Maplewood, and Colette Leatherd, West Drive.

01254 821777

[email protected] [email protected]

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The relational security wheel is displayed on magnetic boards in each ward office and is updated in real time to reflect the temperature and events on the ward.


01254 821777


Chichester Centre

The service has an effective leadership and management structure. Frontline staff reported feeling supported by management and felt their visible presence on the wards to be positive.

Nick Badoorally


Farmfield Hospital

Another area that was noted as a strength for the service was the 9am meetings with a cross–section of clinical staff. Each day representatives from each ward and each discipline meet for a 9am meeting to handover about all aspects of the service and plan the coming days. It was clear that this has been very well developed and is of value to all of the staff at the service.

Mark Watts 01293 787500 [email protected]

Llanarth Court Bespoke training is available for all staff, and each new staff member is included in the staff buddy system.

Dr Phil Huckle


Newsam Centre

There are currently five social workers linked to the wards, which is a great resource and has a positive impact in ensuring the ongoing links with home area services and supporting the pathways out of the service.

Mark Dodd 01138 556 467 [email protected]

Oaktree Manor The peer-review team were impressed that the service have weekly staff meetings for the service as a whole.

Beatrice Nyamande


Rathbone LSU

the service have employed a Bridge Builder who plays a vital role in developing and maintaining links with the community, providing an important role in supporting patients’ inclusion into everyday community activities. This role is beneficial for longer term patients who are socially excluded as well as helping prepare patients for successful discharge.

Sara Finlayson


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The service are on track with regards to improving and developing two integrated services, that provide for both patients with Learning Disabilities and Mental Health issues. This is further emphasised by the service having a team of committed staff for each unit, as well as a crossover of Occupational Therapists, Psychologists, Learning Disability Nurses, and Mental Health Nurses to share expertise and good practice.


Shannon Clinic The training programmes available to staff are comprehensive and there were CBT and DBT trained staff at the service.

Noel McDonald


Shannon Clinic The stable nursing population at the service shows clear dedication and well-trained staff present at the unit.

Noel McDonald


St. Magnus

The peer-review team were pleased to note that there are a number of additional services on offer, such as: a Dementia Nurse Specialist, Art Therapist and Music Therapist. In addition it was also reported that morale and staff retention is high which maintains consistency of care.

Dr Patrick O’Sullivan



It was impressive that training is booked 3 months in advance so that there is always cover for staff. All staff, including bank staff, are part of a thorough training programme, including substance abuse, DBT awareness, gender-specific training, and there is access to the service at Northampton via video link enabling staff to watch academic presentations and ward cases, which is praised by the peer-review team.

Imogen Mortiboys



There is a training suite within the service for all in-house training, which helps to facilitate the extensive training programme that is on offer.


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Each morning the senior staff meet to discuss updates from the wards, in addition to the ward based handover that happens at the change of shift. This was noted to be a great way of sharing information and works effectively. It was also reported that information from these meetings can be fed down through the hospital to community meetings when required.


St. Andrew’s Nottingham

Staff members are given a booklet of profiles for all of the Senior Clinican team and can choose a supervisor fwho best reflects their role and any areas of interest that they may have.

Elizabeth McKeever


Sutton’s Manor

All staff members must record supervision sessions on a central database. This database then uses a traffic light system to alert staff when they are due to receive another session. In addition, supervision passports are utilised in the service to record informal supervision, which is then inputted onto the electronic system.

Alan Jackson 01708 687398 [email protected]

Tony Hillis Wing

All staff receive monthly clinical supervision and reported feeling supported by senior management to do their jobs. Monthly meetings take place which encourage reflective practice.

Dawn Harwood

020 83548600 [email protected];

E: Governance


Governance Department is responsible for complaints and then are monitored electronically. Themes of issues are noted and hospital is currently setting up a service user development group to look at complaints themes.


01254 821777


Huntercombe Hospital East Yorkshire

Yorkshire and Humber support meetings are attended with other units in the area in order to review and learn from incidents that have occurred.

Mark Rice-Thomson


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Woodlands House

Untoward incidents are continually monitored through Clinical Governance Committee and learning points are identified Trust wide. Action plans are reviewed and signed off post action for all wider issues.

Jude Deacon 0845 219 1236 [email protected]

F: Equalities

All Saints Hospital

There is access to deaf clubs and centre, and it is commendable that the service give patients £250 a year to spend on activities that are an interest to them.

Wendy Connolly


All Saints Hospital

There are plenty of opportunities for patients to give feedback and input into the running of the service, through patient meetings, forums, and service meetings. Patients and family are both encouraged to be involved within CPAs and care plans, and this is commendable.

Wendy Connolly



There were clear information boards on the CQC, the MDT, feedback from meetings/complaints, any changes occurring, CQUINS, and human rights, to name a few.

Dr Anthony Fernando


Annesley House

Supervision type sessions have been allocated to carers for every 6-8 weeks to check-in with them and ensure their needs are supported fully. This contact is reduced over time when the need is lesser. The service also reported that they were developing a carer newsletter to open up communication with carers and to include educational sections to improve understanding of issues related to forensic mental health.


Ashley House

Ashley House involve the patients in the daily running of the service, for example, patients are part of the staff recruitment process and risk assessments.


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Bowman Centre

During the tour of the unit the review team noted a number of information boards covering range of topics. The team were particularly impressed with the Mental Health Act board providing patients with easily accessible information about the act and what different sections mean in relation to individual rights.

Michaela Burt



There are number of patient involvement opportunities, such as: writing articles for the hospital newsletter, creating health promotion materials and a DVD, and creating a video tour of the hospital that is used on the hospital website for patients and carers to view.


01254 821777



It is commended that representatives from each ward are involved in patient meetings and patient representatives are involved in Governance Board meetings.

David Williams



The Catering staff and their motivationwas highly impressive as they are responsive to the needs of the patients, and are flexible to adapt when patients wished to eat something different.

David Williams


Clifton House

As patients progress along their pathway, there is the option for a mixture of self-catering and hospital provided food or fully self-catered, with their own shopping budget. Patients were very positive about the self-catering options and reported that the hospital provided food was of a good quality and variety too. The team also praised the practice of staff eating meals with patients.

Beverley Hunter



The team were also very positive about the real and normalising experience of eating in the hospital restaurant as soon as they have leave to do so. This was seen as a great facility for the service especially with the opportunities it provides for patients to eat with staff, family and friends formal restaurant setting.

Navin Ramgolam


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the quarterly carers support meetings were noted to be a major achievement for the service who have a 90% attendance rate. It was praised that the service are able to provide support for carers to access these quarterly meetings, which are held on Saturdays and followed by visiting sessions.

Navin Ramgolam


Cygnet Hospital Kewstoke

Patients are fully integrated within the service, with a weekly ‘Friday Meeting’ which is a chance for patients to give feedback and receive a response from the service the following week. A ‘Have your say’ group is also attended by patients and is chaired by an independent advocate.

Barry O’Driscoll 01934 42898 [email protected]

Eaglestone View

Peer-review team commended the 'Adopt a station' scheme that gets patients involved in the upkeep and environment of a local railway station.

Malcolm Campbell


Eaglestone View

Patient representatives attend all staff interviews, and are able to ask questions as a member of the interview panel.

Malcolm Campbell


Eric Shepherd Unit

Patients reported they receive weekly visits by the independent advocate and can request one to one sessions as and when required. The advertisement of the advocate included many posters and descriptive leaflets available for patients, making the advocate approachable.


Hazelwood House

The peer-review team commended the buddy system in place at Hazelwood House. New patients are paired up with one already residing at the hospital. Prior to admission phone calls take place between the patients for any queries to be answered and for the new patient to feel settled as early as possible after they arrive. The patients reported they found this system very beneficial and encouraged the further use of this.

Palmer Chinosengwa


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Hillis Lodge

The unit has adopted a practice of positive risk-taking by allowing previously prohibited items into a low secure setting, for instance lamps and easily movable furniture.

Jan Morris 0121 678 3000 [email protected]


Each of the bedrooms are painted in different colours and patients were able to choose the colour room that they wanted. It was also clear that there was a great deal of patient involvement in developing parts of the ward, such as the soft room and the beauty parlour.


Kemple View

it was noted that patients spoke highly of the patient’s council. Upon examining the meeting minutes the peer-review team were pleased to see these were up to date and that there was evidence that action had been carried out regarding feedback from patients.

Mags Gallagher


Kneesworth House Hospital

Patients has recently been involved in planning, carrying out and analysising an audit on their involvement in governance meetings.

Linda Ram 01763 255 700 [email protected]

North London Clinic

Community meetings take place three times per week on Mondays, Wednesdays and Fridays, and the meetings were run by the patients at the service.

Gary Stobbs 0208 956 1234 [email protected]

North London Clinic

A catering manager was able to come onto the ward to speak to patients at the service and the food provided.

Gary Stobbs 0208 956 1234 [email protected]

Oxford Clinic

Patients spoke highly of the advocate and viewed as a valuable tool. In addition to this, patients were very clear on how they could contact the advocate and how quickly they could be seen.

Jude Deacon 01908 243056 [email protected]


Patients reported being involved in the service in a manner of ways, including daily meetings and monthly ‘my service’ meetings. In addition, patients described how they have been involved in the building of the new ward, and felt their ideas had been listened to.


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Shaftesbury Clinic

Service user rights were clearly read and respected by all at the service, and meeting minutes are taken in both the community and visitors meetings.

Kirsty Murray

020 3 513 6060 [email protected]

Southfield The service are looking at the use of video conferencing to support links with families and with home area care coordinating teams.

Luke Birmingham


St. Nicholas Hospital

The service are able to offer both individualised activity timetables, as well as drop-in access to sessions when requested.

Shirley Wakefield

0191 223 800 [email protected];


Food was acknowledged as an area of achievement by patients. There are a range of choices, patients are able to ask for specific meals when required, and patients on Maldon ward are able to self-cater and are involved in purchasing the items and cooking both for themselves and for the ward.


St. John's House

The peer-review team were impressed with how patient-led the service is, with many ways for patients to be involved; whether it is through community meetings, joining managerial meetings, or completing surveys – there is plenty of opportunity for patients to voice their opinion.


Wells Road

Patient involvement was evident across all aspects of the service, allowing patients to take responsibility for their own care and promoting service improvement. A few examples of patient involvement include; community meetings on each ward, patient representative roles, sitting on interview panels for new staff, listening events and ‘safe space’ meetings. The patient group reported that the service strives to cater for all and that it is very inclusive in its approach.

Jeremy Resnick


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Wells Road

To develop support for carers and to enhance understanding of their needs to the staff team, the service arranged for carers to come in and talk about their experiences. The service developed a family and friends contact plan to learn of their individual preferences when communicating effectively with the MDT. In addition there is a family and friends hotline that allows carers to gain immediate support over the phone. The service was also praised for their customer care approach of dealing with carers, providing training in this area for reception staff and placing visitor feedback postcards in the reception area.

Jeremy Resnick


Wolfson House

Patients regularly attend User Involvement Group (UIG) meetings, where they voice their opinions, and are able to make changes to the service. From these meetings, vending machines supplied with healthy foods have been introduced, Friday night discos launched, and the service will soon be removing the mats out the gym and setting up free weights, at the patients’ request. There are also food tasting groups, so that patients are able to try the food and give feedback.

Deborah Bull 020 8510 2003/4/5 [email protected]

APPENDIX C: EXAMPLES OF GOOD PRACTICE LSU Cycle 2 Good Practice.pdf · APPENDIX C: EXAMPLES OF GOOD...

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