Calderstones Partnership NHS Foundation Trust

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Calderstones Partnership NHS Foundation Trust
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SPECIAL PROJECT (INTENSIVE SUPPORT PACKAGE)
CARE IN CALDERSTONES
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• Calderstones Partnership NHS Foundation Trust is
  a regional provider for adults with a
• learning disability with complex needs who
  cannot be supported by other
• organisations. There are 218 beds around the
  main site, comprising 36 medium
• secure and 182 low secure and open beds in flats
  and peripheral houses.
• Some service users have difficulty forming
  relationships with peers, sharing staff,
• coping with changes in staff and peers, and with
  lack of structure in activities.
• Individuals with autism, autistic spectrum
  disorder and brain injury fall into this
• category. They benefit from a skilled,
  experienced stable staff team, consistent
• approach and a programme of predictable
  activities.
•  
• I will present seven patients managed with
  intensive support packages (special
• projects), detailing brief histories, diagnoses
  and costs of care.
• I will then discuss the implications for
  community care and the challenge to
• normalisation and inclusion.

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PATIENT A

• A 48 year old woman who transferred to
• Calderstones in 2006 from a general adult
• psychiatric ward on Section 3, detained under
• severe mental impairment. She had been
• admitted following an attack on a child in the
• street, at a time when care staff reported they
• could no longer manage her levels of violence.

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Patient A

• DIAGNOSES
• F71.1 - Moderate mental retardation
• Bipolar Affective Disorder unclassified
• Probably Autistic Spectrum Disorder
• COST OF CURRENT CARE
• 8.5 staff - 233,883

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PATIENT B

• 21 year old woman with moderate mental
  retardation
• and pervasive developmental disorder.
  Transferred to
• Calderstones in February 2006 on Section 3.

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Patient B

• DIAGNOSES
• F71.1 Moderate mental retardation
• F84 Pervasive developmental disorder
• COST OF CURRENT CARE
• 11 staff - 289,424

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PATIENT C

• Transferred, aged 18 years, to Calderstones in
  2006
• on Section 3. Diagnosed with severe mental
• retardation and Autistic Spectrum Disorder. Long
• history of serious aggression (grabbing, biting,
• scratching and hitting), damage to property, pica
  and
• self injury including inserting material into his
  nose and
• biting himself. At the time of admission he was
  doubly
• incontinent. He would defecate and smear faeces
• on himself, walls and on staff.

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Patient C

• DIAGNOSES
• F72.1 Severe mental retardation
• F84 Pervasive developmental disorder
• Diagnosed with
• Chromosome 22 q level deletion
• COST OF CURRENT CARE
• 13 staff - 338,862

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PATIENT D

• 40 year old man transferred to Calderstones on
• Section 3 from a high secure hospital in April
  2006

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Patient D contd..

• DIAGNOSES
• F71.1 Moderate mental retardation
• F07.0 Organic personality disorder
• COST OF CURRENT CARE
• 21.50 staff - 588,364

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PATIENT E

• Admitted to Calderstones at the age of 15 years -
  over one hundred services having refused
  admission. No child service felt that they could
  meet his needs. He had been placed outside his
  home district at the age of 13 years into the
  independent sector provision. Due to his
  difficult and violent behaviours he was admitted
  into the NHS. He was nursed on his own on an
  adult intensive care unit for over 5 months.

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Patient E

• PRIOR TO ADMISSION TO CALDERSTONES
• He required a team of 23 staff covering a 24 hour
  period to provide physical restraint for the
  entire time he was awake, at a cost in excess of
  1.25 million per annum.
• DIAGNOSES
• F70.1 Mild mental retardation
• Tourettes syndrome
• ADHD
• Autism
• COST OF CARE ON DISCHARGE FROM CALDERSTONES
• 16.50 staff- 449,460

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PATIENT F

• 40 year old man with mild mental retardation,
  organic personality disorder secondary to head
  injury, recurrent depressive disorder and
  undifferentiated schizophrenia. Admitted to
  Calderstones informally in 2001 following a
  breakdown in a community placement for a special
  project care package to manage very high levels
  of physical aggression and damage to property.
  He threatened to self harm and had become head
  injured and paraplegic from jumping off a bridge
  in a suicide attempt aged 26 years. He was
  detained under Section 3 in January 2002.

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Patient F

• DIAGNOSES
• F70.1 - Mild mental retardation
• F07.0 Organic personality disorder
• Recurrent depressive disorder
• Undifferentiated schizophrenia
• COST OF CURRENT CARE
• 13 staff - 338,862

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PATIENT G

• A 35 year old man moderate mental retardation and
• pervasive developmental disorder, transferred to
• Calderstones on Section 3 from a temporary
  placement
• in the private sector. The community placement
  has
• not been able to manage his level of physical
• aggression and were concerned about his threats
  to kill
• staff and stab them.

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Patient G

• DIAGNOSES
• F71. 0 Moderate mental retardation
• F84 Pervasive developmental disorder
• COST OF CURRENT CARE
• 14 staff - 373,040

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COSTINGS FOR INTENSIVE SUPPORT/SPECIAL PROJECT
CARE
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DISCUSSION

• Individual intensive support package costs
  between 2 to 4 times that of other patients in
• Calderstones. They are funded by the Secure
  Commissioning Team who set a budget of 2 million,
• which is closely monitored.
• Districts are going to have a dilemma to fund
  expensive individual care or to focus on more
• general provision for service users.
• High numbers of staff are involved which can be
  found from the large pool of skilled experienced
• workers within the hospital institution.
  Individual community care packages run the risk
  of staff
• burn out and need to use agency or bank staff to
  cover sickness and holidays.
• They do not have access to large numbers of
  experienced skilled, trained staff.
• The way forward for complex community care
  packages would be to design services to provide
• for small numbers, for example 3 to 5 individual
  staffed flats within one site. One district
  could
• potentially sell the resource to other districts
  ,or there could be joint funding.

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• These facilities could be seen as a step in
  rehabilitation or, for some individuals, long
  term
• providers.
• All the patients presented lacked capacity to
  consent to the physical restraint that was needed
  
• at times to manage physical aggression. They
  were in receipt of 24 hour supervision with
• restriction of their liberty. It is debateable
  as to how these restrictions could best be
  legally
• supported through the Mental Health Act,
  supervised community treatment order or
• Guardianship, or through the Mental Capacity
  legislation.
• In all cases there would be concerns about
  emergency admissions to general adult psychiatric
• provisions, when a place of safety may be the
  intervention required.
• Community care staff would need to be skilled and
  confident in using physical restraint
• techniques in the least restrictive way. They
  would need knowledge and experience in managing
• individuals with autism or head injury.

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• The current emphasis on normalisation and
  inclusion does not encompass risk management
• and mitigation. The patients presented all
  potentially place themselves and others at risk
• through their behaviour. They are sensitive to
  overstimulation and each patient requires
• their individual needs and risks to be recognised
  and managed.
• Intensive support packages can be demonstrated to
  significantly reduce the harm to patients
• and to others. Commissioners need to understand
  that it is not always possible to reduce these
• risks and reduce costs of care.
• Some of these packages may be needed for
  considerate periods of time to maximise the
• quality of life of the service user and manage
  risks to the care providers.

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Thank you for listening.