Controlled physical restraint is a commonly used, but controversial practice in inpatient psychiatric settings, at times bringing psychiatric practice into potential conflict with accepted medical ethical standards for preserving autonomy and bodily-integrity. However, physical restraint can produce high levels of patient distress, re-traumatise those who have experienced physical or sexual abuse, and may lead to inadvertent bodily injury, and even death on rare occasions. There is an international consensus to attempt to reduce restrictive practices, including physical restraint, as demonstrated in the World Health Organization's Quality Rights Initiative. Post-restraint patient debriefing can promote recovery, prevent future restraint, and promote a more ethical and humanising care environment.

We aimed to audit the frequency of restraint events, and post-restraint debriefs offered to patients in a single, London-based, male acute psychiatric ward.

In the pre-intervention sample, data was extracted from the records of patients admitted over a six-month period (n = 75), to identify the number of patients who had undergone restraint and the number who had been debriefed. The search terms “restrain”, “PMVA”, “response team” and “debrief” were used. After each restraint event, the notes for the following two weeks were reviewed to see if a debrief was delivered.

The intervention consisted of a single description and dissemination of the results in a ward business meeting, with instruction that all staff members within the ward multidisciplinary team can help provide debrief if appropriate to do so. Where a patient was known to have been restrained, debriefs were offered during subsequent ward round reviews as appropriate.

In the post-intervention sample, we collected data from patients admitted over a 10-month period (n = 89).

We used Chi-Squared testing to compare categorical variables pre- and post-intervention.

Pre-intervention, 15 patients underwent restraint and of these, 8 patients (53.33%) were debriefed. Post-intervention, 21 patients underwent restraint and of these, 10 patients (47.62%) were debriefed. There was no statistical difference in the proportion of patients offered a psychological debrief (p = 0.735).

Following a single intervention there was not a sustained difference in the proportion of post-restraint debriefs offered. It is likely more sustained interventions would bring about more substantive practice change. Incorporating the need for post-restraint debriefs in daily ward safety-huddles, or in structured “ward round proformas”, may increase the proportion of patients offered post-restraint debriefing. It is possible that the note review strategy did not capture all debriefs delivered.

The urgent referral system to outpatient psychiatry in NHS Lothian is intended for patients who require to be seen within 5 days. However, many of the referrals are not deemed this urgent upon triage. This project aims to illustrate the extent of this issue and highlight potential reasons, in order to improve the pathway for patients referred on to secondary care services.

Over a 3 month period from August 2023 to November 2023, all urgent referrals received by an Edinburgh sector general adult psychiatry outpatient's department were reviewed. Data was collected on broad presenting complaint, whether or not the referral was deemed urgent upon triage, whether it contained a factor in line with RefHelp guidance for urgency, and what the end outcome of the referral was.

During the 3 month period, there were 92 urgent referrals. Of these, only 12% were deemed urgent upon triage. Almost all accepted referrals related to concerns around potential psychotic illness (82%). Although only 12% of referrals were accepted as urgent, 35% had factors which, in accordance with RefHelp guidance, would be cause for considering an urgent referral.

There were a variety of disposals including “soon” appointments, redirection to other services such as Thrive or offering advice to the referring clinician. The most common outcome was the offer of a “soon” appointment, closely followed by redirection to the Thrive team.

The majority of urgent referrals were not deemed urgent at triage. There was a clear discrepancy between referrals containing urgency factors according to RefHelp and those offered urgent appointments. This would suggest that the available guidance is not sufficiently clear.

Many referrals were redirected to other services, including Thrive. This redirection may reflect a lack of awareness and a further project may examine Thrive referrals to establish if the number initially sent to psychiatry outpatients is significant.

Additionally, several referrals were triaged as “soon” and seen in 6–8 weeks, as opposed to waiting for a routine appointment. Though RefHelp advises highlighting routine referrals which may be a priority, this pathway was not being used and there is no direct route for “soon” referrals.

Next steps may include liaison with primary care teams to establish views and concerns, updating RefHelp guidance and adding a further referral pathway to address the apparent gap for “soon” referrals.

We conducted a quality improvement project in a female rehabilitation unit, with an aim to reduce the total anticholinergic burden.

Most patients were reluctant to change the medications that they have been taking for long time. Hospital staff were also concerned about the potential risk of destabilising the mental health of patients who are currently stable.

As a first step, we used ACB (Anticholinergic Burden) calculator to calculate ACB score

We agreed on a realistic safe target. We decided not to include patients who are on clozapine. Information related to anticholinergic burden was shared with nursing team and staff members. This was discussed in MDT meetings to answer any questions.

Team collaboratively created an information leaflet, including an easy read version. Group sessions and 1:1 sessions were arranged with patients to discuss the potential side effects.

Medication changes were carried out following a consultation with patients.

ACB score of all 15 patients were over 3. One patient is over the age of 65. Five patients scored more than 10 on total ACB score. Two patients were on clozapine.

Promethazine, procyclidine, hyoscine hydrobromide, oxybutynin and clozapine were causing most of the anticholinergic burden.

We decided not to change medications of two patients who were on clozapine. For the remaining patients procyclidine and promethazine were reviewed and stopped following a consultation. All 12 patients' ACB score is now less than 10. There has been a reduction of 3–6 points.

This project has helped in reducing the ACB burden successfully. Promethazine with an ACB score of 3 was stopped for all patients. Some patients received promazine instead of promethazine. Procyclidine has been stopped for several patients and for some patients it has been changed from regular to PRN (to take when required). Consideration has been given to reduce the dose of typical antipsychotic medication instead of using procyclidine to treat extrapyramidal side effects.

Providing information and then reviewing the prescription of promethazine and procyclidine has resulted in significant reduction in the total ACB score.

Patients not attending appointments without letting the service know prior (referred to as did not attend – DNA) is a significant problem in community mental health (CMH). However, there are limited studies conducted in the United Kingdom on this issue. Patients forgetting appointments was a reoccurring reason for DNAs in the literature. To address this, we aimed to assess the impact of raising staff awareness on recording patient consent to receive text message reminders of appointments and increasing the frequency of reminders on DNA rates in Arndale House (a CMH service covering Dartford, Gravesend and Swanley as part of the Kent and Medway NHS and Social Care Partnership Trust – KMPT).

DNA rates at Arndale House from August to October 2023 were assessed to determine a baseline before implementing interventions. Following this, two interventions were put in place; the first occurred on 18/10/23, consisting of an online teaching session for the staff at Arndale on documenting patients’ consent to receive text message reminders for their appointments. Posters with instructions on this were posted on the trust intranet and set up within the building. The second intervention occurred on 20/11/23 and included sending out text message reminders more frequently, from three and one day prior to appointments to seven days beforehand as well. DNA rates for November were analysed to assess the impact of intervention one and December for intervention two. Patient characteristics were also examined monthly to identify any trends among those who DNA. The analysis comprised 109 patients (69 for pre-intervention, 27 for intervention one, and 13 for intervention two).

Pre-intervention DNA rates were 13.4%, 17.5%, and 13.5%, respectively. The incidence of DNA increased to 19.9% after intervention one. However, this was lower than November 2022. The rate for intervention two was 11.6%, lower than that of December 2022. Being White, having a mood disorder and having mental health disorders which fell under more than one category were prominent among those who DNA.

Increasing the frequency of text message reminders of appointments had a significant impact on reducing DNA rates, highlighting a potential intervention which can be implemented in CMH to tackle the issue of DNAs.

The Quality Improvement Project (QIP) for the Café of Royal College of Psychiatrists (RCPsych) Portfolio (CoRP) was initiated to address the challenges faced by UK postgraduate psychiatric trainees in utilizing the RCPsych Portfolio effectively. The primary objective of this project is to enhance trainees' confidence and competence in using the portfolio. Additionally, CoRP aims to establish a robust, sustainable ecosystem of peer coaching and mentorship to support continuous learning and development among trainees.

The CoRP employs a unique, multi-faceted approach, leveraging a scalable coaching and mentoring model. Firstly, the program focuses on increasing its visibility among trainee groups through targeted communication and marketing efforts. Secondly, CoRP provides on-demand sessions to cater to the varied schedules and job plans of trainees, offering flexibility and accessibility. The sessions offer a mix of coaching, mentorship, and guidance, tailored to the specific needs and learning styles of each trainee. Furthermore, the project fosters an environment where trainees can learn from peers and experienced professionals, enhancing the learning experience and promoting a culture of collaborative learning.

The implementation of the CoRP has led to significant improvements in trainees' confidence in using the RCPsych Portfolio. This outcome is evidenced by the data collected from pre- and post-session surveys, which show a marked increase in trainees' self-reported confidence levels. The project has successfully conducted a series of sessions that focus on various aspects of portfolio management and learning. These sessions have been well-received, with positive feedback from participants indicating that the program meets its intended objectives. However, the project acknowledges the need for long-term data to understand its impact on the Annual Review of Competency Progression (ARCP) outcomes and to assess its sustainability over time.

The CoRP has demonstrated immediate, positive effects in enhancing the skills of psychiatric trainees in using the portfolio. Its strengths lie in the scalability of the model and the incorporation of coaching and mentorship principles, which have proven effective in addressing the needs of trainees. However, the project recognizes that further evaluation is needed to establish a clear correlation between improved portfolio skills and ARCP outcomes. To this end, future plans include the continuous expansion and repetition of the program every six months to accommodate new trainees. Additionally, ongoing evaluation will be conducted to measure the program's long-term effectiveness and sustainability. This will ensure that CoRP continues to evolve and adapt to the changing needs of psychiatric trainees, ultimately contributing to their professional development and success in their field.

To explore reasons why patients under the learning disability community psychiatry team were not attending their appointments.

To explore patient preferences for type of appointments offered (F2F, telephone or video) aiming to improve access and attendance, whilst promoting reasonable adjustments for patients with learning disabilities.

To improve efficiency in terms of number of patients seen and reduce wasted clinical and admin time in relation to DNA appointments, by reducing the ‘did not attend’ (DNA) rates by 20%.

With the support of the QI team using methodology including fishbone diagrams and PDSA cycles, electronic data on the number of DNA psychiatry appointments were collated from January 2022 onwards and recorded monthly.

Each DNA appointment was coded with a reason given for non-attendance. The data was then reviewed and analysed to identify any common themes around non-attendance.

A questionnaire was initially trialled with a small sample of patients who had not attended to explore reasons for non-attendance and preference regarding appointment type. The questionnaire was then sent to all CTPLDW patients who had missed appointments. An easy-read version was also sent to promote accessibility amongst the patient group. The data was collated and reviewed.

Most common reasons for patients not attending their psychiatry outpatient clinic appointments under the CTPLDW team were identified:

2022: 35 patients DNA – 28.6% citing communication/correspondence issues.

2023: 30 patients DNA – 33.3% citing communication/correspondence issues.

Additional reasons for non-attendance included issues with residential homes, sickness and transport.

An anecdotally high number of DNAs were noted by CTPLDW. The data collected thus far has helped us to define and understand the issues. The main factors identified revolve around communication and correspondence of appointment times.

The next step in our quality improvement project is to trial text reminders for patients and carers to assist in remembering appointments, to assess whether this change idea helps to decrease the number of DNAs.

Future change ideas include development of resources to support attendance (e.g. adjusted appointment letters with QR codes for access/maps, reminder letters in easy-read format and video tours).

CTPLDW would like to offer a more personalised approach with a service that promotes reasonable adjustments and reduces barriers to access, thereby reducing the number of DNA appointments.

Background: Handover aims to achieve the efficient communication of clinical information when responsibility for patients is transferred. The Royal Edinburgh Hospital (REH), a specialist hospital serving the Lothians, has repeatedly received “red flags” (ranked in the bottom 2% of benchmarked areas) on the handover section of the Scottish training survey (STS) and GMC national training survey of doctors in training (DiT).

Aims:

• • Survey DiT to understand their experience of handover.

• • Introduce a new structured handover process.

• • Re-audit parameters after intervention.

Data from REH DiT were extracted from an anonymised handover survey, disseminated to all psychiatry DiT in Scotland in January 2023. Multiple choice and free-text questions covered handover timings, format, structure, and attendance. The survey was repeated after intervention. In addition, data from the STS were analysed. The intervention consisted of altering shift times to include protected time for handover, introducing a dedicated room, training in the use of an electronic system to record tasks, involvement of senior doctors, and dissemination of the new changes to procedure.

A total of 12 survey responses (25% response rate) pre-intervention (25% FY2s, 17% GPSTs, 58% core trainees) and 14 post-intervention (14% FY2s, 14% GPSTs, 71% core trainees) were analysed. The proportion of respondents reporting that handover always happened at times of shift change increased from 7% to 93% post-intervention. The proportion of those reporting that there was protected time for handover rose from 0% to 50%, and the use of a predetermined structure/format increased from 0% to 43%. After intervention, 86% of DiT felt adequately supported during handover (compared with 17% pre-intervention) and 93% of respondents felt handover ‘allowed for the efficient and effective transfer of information to protect patient safety’ (33% pre-intervention). Prior to the process change, 83% of DiT felt there was no clear senior leadership at handover; this fell to 21%. Post-intervention the use of WhatsApp/texts to hand over information fell by 100%. The new system was welcomed by trainees, but teething problems were identified.

The new process led to improvements in the frequency, consistency, format, recording, and senior support of handover. Issues with the use of video call software and electronic medical records systems have been identified, and work is ongoing to address these in an iterative quality improvement process. Good clinical handover benefits patients (fewer mistakes and increased safety, better continuity of care, improved satisfaction) and clinicians (improved communication skills, increased accountability, feel more informed, improved job satisfaction).

Background: Nature and degree of mental illness can impair abilities of patients to drive safely which puts their own safety and safety of others at risk. There is also an ongoing concern of patients not being properly informed on their duty to inform the DVLA and potentially to stop driving for an extended period.

Aims:

1. 1. To assess if risk assessment of patients in term of driving status was completed at time of admission, during their stay on ward, and if any advice regarding fitness to drive was given at time of discharge.

2. 2. To improve patients being asked about driving status on admission to 100% of patients.

3. 3. To improve rates of service users being informed of the DVLA guidance following a mental health illness to 100% of patients.

It is a Quality Improvement (QI) project. Baseline information on current practices were assessed against local fitness to drive policy of Leicestershire Partnership NHS Trust in May 2023. Data was collected from 10 inpatient (6 general adult & 4 old age) wards. All patients who were discharged in the month of January 2023 were included for audit. Information was collected about driving status of patients at time of admission, during their stay on ward, and if any advice regarding fitness to drive was given at time of discharge. Data was recorded anonymously. Results are reported in percentages for descriptive statistics.

Risk assessment was completed in 95% of patients on admission. About 12% (15/128) of the patients were driving at the time of admission, 80% of them were female. Assessment of driving risk during admission only took place in 11.7% (13/128) of cases. Advice on fitness to drive at time of discharge was given only in 12.5% (16/128) of cases. About ¼ of patients who were driving at time of admission, did not receive advice on fitness to drive at time of discharge from hospital.

There is a huge gap in clinical practice regarding compliance with fitness to drive policy. There is an urgent need to improve awareness among mental health teams that they have a role with regard to assessment of their patients’ risks and fitness to drive. An educational training video will be prepared and shared with clinicians in December 2023 to fill gaps in the service. Further information will be collected on practices related to fitness to drive policy in March 2024 for further evaluation of services.

To identify professional and organisational-related themes in Coroners' PFDs reports which contributed to mental health related suicide.

We reviewed Coroners' PFDs reports via the UK Judiciary website. We filtered reports by those which were mental health related deaths and included the keyword ‘suicide’. 100 reports were reviewed starting with the most recent which was August 2023. We reviewed which Coroner's area the reports originated from and the age and gender of the deceased. Then, we examined the contents of the PFDs reports including the inquest conclusion, circumstances of death and concerns raised by the coroner. Themes were identified and grouped into patient-related, professional-related, and organisational-related factors that may have contributed to the death by suicide.

Reports were reviewed from across the UK. The highest number of reports were from the coroner area of Manchester South (12%).

From those reports whereby the deceased's age was mentioned, the mean age was 36 with an age range of 14–81 years (35% of reports did not include the deceased's age).

61% of reports were of males and 39% females.

The main professional-related factors identified from thematic analysis of the PFDs reports were issues around risk assessment and management (45%), lack of interprofessional communication and collaboration (33%), inadequate clinical queries/assessment (25%), lack of consultation of family/carers (17%) and lack of treatment/follow up plan following discharge (11%).

The main organisational-related factors were inadequate service provision for the population covered (20%), inadequate training/knowledge (18%), inadequate staffing or reliance on agency staff (15%), poor systems in place including information technology (13%) and lack of audit or evidence of learning from prior investigations & events (11%).

Patient-related factors were less commonly identified but included lack of engagement with services, denying suicidality and autistic spectrum disorder.

The commonest theme was issues around risk assessment and management which was identified in 45% of suicides. It is hoped by highlighting common themes arising from PFDs reports across the UK this analysis could inform targeted improvements in practice that will lead to reductions in mental health related suicide which is the need of the hour.

Patients with severe mental illness are at a significantly higher risk of poor physical health outcomes than the general population and die on average 15–20 years earlier. The Royal College of Psychiatrists has published extensively on how to improve routine physical health monitoring in this cohort. Despite this, there is little data or guidance on improving emergency medical care for this cohort. We aimed to analyse and optimise the process of patients being sent to general hospital on an emergency basis.

A review was undertaken of the clinical notes for medical emergencies over a 12 month period by two core psychiatry trainees. Site visits and interviews with local A&E department clinicians, the covering General Practitioner and pharmacy were completed. A questionnaire was distributed to all nursing staff to gather their perspective on the considerations for emergency medical transfers out of The State Hospital.

On review of the case notes, 44/44 emergency outings were deemed to be clinically necessary for investigations/interventions that would not have been possible on-site. Qualitative methodology highlighted a disconnect amongst staff groups and stake holders regarding thresholds for transfers relating to medical emergencies leading to a high level of staff dissatisfaction.

The interface between psychiatric and medical services is an area of risk to patients. Levels of staff confidence, knowledge and available resources all contribute to the risk of transfer. Further work is required to explore other aspects of patient care and treatment which can be impacted as a consequence of emergency transfers.

• • To improve safe medication prescribing by achieving a 25% improvement in the number of cases reported in the practice within six months.

• • To reduce human factors contributing to medication errors to improve patient safety and quality of care.

• • Retrospective data collection was done for Halton and Widnes patients from March 2022 to April 2023;

• • Retrospective data collection for Re-audit was done for a period between June 2023 to January 2024 to complete the audit cycle;

• • Liaised with medicine management team for local practices/policies;

• • Reviewed and verified Trust standardised local policies on medicine management;

• • Reviewed incident data and checked processes in other teams;

• • The findings were presented at the Medicine Management meeting in May 2023;

• • Training on safe prescribing was delivered to the Memory team in June 2023.

• • During the first data collection period, 14 incident forms were reported.

• • During the second data collection period, 1 incident form was reported which was an administrative error.

• • Prescribing errors for the first cycle accounted for 28.6%, administrative errors for 35.7%, dispensing errors for 21.4%, and other errors for 14.3%.

• • Specific error types included prescribing the wrong dose/medication, medication not prescribed, medication unavailable and double prescribing.

• • No incidents of restraint, seclusion, rapid tranquillisation, ambulance calls, or RIDDOR were reported.

• • Administrative errors accounted for the majority of the total reported incidents (35.7%).

• • Recommendations include safe clinical practice of prescribing medication (MDT lead to update medication card and inform GP promptly).

• • Other recommendations were medication card updates, aligning clinical systems, avoiding email requests and introducing Community EPMA (Trust objective to introduce EPMA to community teams in 2024/25) and to standardise procedures.

• • An improvement of 92.9% in the incident reporting was found in the re-audit following a training session to the team with improved practice of no email requests or chains.

• • The audit identified communication difficulties within memory services, primary care and care home.

• • It also highlighted challenges related to new staff, post-MDT meetings medication card updates, prescriber preferences, geographical disparities, and doctors’ availability.

The aims of the study were to illustrate the number and type of restrictive practices that were used across two inpatient wards within the Acute Mental Health Inpatient Centre in the Belfast trust over a two year period. This initially would highlight the prevalence and use of such practices and allow for comparison against the data collected after the implementation of the therapy cross. We hoped that with the implementation of the therapy cross we would see a decline in the use of physical interventions, use of IM medications and also the number of aggressive or distressing incidents and behaviours would also decrease.

We utilized a statistical process control to collate and illustrate data. Daily data collection was carried out and compiled over a 2–3 year period and is ongoing with regards to ward incidents of aggressive behaviour, use of physical intervention, use of IM medications. In early October of 2023 the therapy cross was introduced and the run charts and data collection continued allowing for comparison of such behaviours and interventions pre and post intervention.

A percentage decrease of 50% of the weekly average was noted in incidents of aggressive and violent behaviours on one ward in AMHIC following implementation of therapy. A percentage decrease in average weekly use of IM injections was noted to be 13%. A 12% decrease was found in the use of physical intervention on a weekly average following the therapy cross.

The implementation of a therapy cross in early October 2023 indicated improvement in the incidence of use of restrictive measures on two inpatient wards in the Belfast Trust, including the number of physical interventions such as holds that were required and also decreased the incidence of use of IM medications for rapid tranquillization. The data indicates a significant decrease in the number of cases of violent and aggressive behaviour on wards following implementation of a therapy cross.

We aimed to improve the care for people with intellectual disabilities (PWID) presenting to a community learning disability service (CLDT) with health needs relating to sexual wellbeing, sexuality, and/or gender identity (SSGI). A QI framework was used, focussing on staff education and service development.

We hypothesised that there would be a lack of confidence and staff knowledge around SSGI issues in PWID. We suggested that challenges exist because discussing sex in PWID still feels taboo.

PWID have the same sexual needs as those without any disability. Historically, this population have been discouraged from expressing their sexuality due to certain attitudes, fears, and prejudices. Stigmatising views have included PWID being viewed as asexual or conversely posing a risk of sexual violence, despite evidence showing that they are more vulnerable to sexual abuse. Important issues around capacity and understanding consent highlight the importance of psychosexual education for patients and carers.

Carers and health care professionals are key in educating and supporting PWID, however, our disinclination towards discussing SSGI openly can have unintended negative effects on the wellbeing of our patients. These issues are therefore paramount to understand and address.

Patient-facing staff in a London CLDT were surveyed, and staff focus groups held, to understand attitudes towards SSGI in PWID. Staff knowledge of local services was also explored. Using thematic analysis, we identified both staff and service development needs and devised a set of interventions to address these.

Four educational interventions for staff were developed and evaluated using QI methodology. Interventions included bitesize teaching, externally commissioned training, and resource packs.

Thematic analysis identified a number of barriers to delivering SSGI care, particularly staff's low confidence and a lack of training. Following the four educational interventions, average staff confidence to discuss SSGI increased from 55% to 77%.

Staff responses indicated a lack of SSGI services for PWID locally. In response to this, the QI team, service leads and management agreed upon various service development ideas. These include upskilling specific staff to become SSGI leads; auditing the CLDT caseload to understand the SSGI issues in our population; and trialling a clinical sexology service for a small subset of patients.

A QI approach to staff education demonstrated clear benefit, with staff more confident to address the SSGI needs of PWID. Combined with sustainable service improvement ideas, this can improve patient care.

Problem:

Around 10% of patients with an intellectual disability have a clinically relevant copy number variant in their DNA detected using microarray analysis. Adults with an intellectual disability may not have had access to genetic screening during their patient journey, or they may have had previous screening with now outdated technology.

Aim: to offer up-to-date genetic screening to adults with intellectual disability in an inpatient setting.

Strategy for change:

In collaboration with the clinical genetics department, confirm local capacity for genetic screening by microarray testing, and create a pathway for referral with a screening tool for detection of “high risk” patients. Develop processes and resources for consenting patients with capacity, and for acting in best interests with family agreement for those without.

Measurement of Improvement:

Increase in the number of patients with up-to-date genetic screening.

Effects of change:

This project has detected previously unknown genetic abnormalities in current inpatients, two of which were felt to be clinically significant. Further testing is underway and clinical discussions are ongoing regarding the implication of these findings for current patient care and management.

Discussion:

Patients with capacity, families and multidisciplinary healthcare professionals were overwhelmingly supportive of this project with the aim of improving understanding and ultimately the care of each individual. With further discussion and assistance, this project could be widened to the community setting to benefit a greater number of patients and their families.

1. 1. For all eligible general adult psychiatry and substance misuse inpatients at the Royal Edinburgh Hospital (REH) to be offered appointments at a pilot onsite sexual and reproductive health (SRH) clinic.

2. 2. To evaluate the need for this novel service using eligibility rates and attendance levels.

Eligibility of all inpatients on a substance misuse ward considered at admission, and a space in the clinic offered if appropriate. Reminder added to the clerking proforma.

Eligibility of general adult psychiatry (GAP) inpatients considered by their multidisciplinary team (MDT) weekly. Team 1 to trial this at ward round, and team 2 to trial it at rapid rundown.

A patient leaflet was created to explain the clinic.

General adult psychiatry: In team 1, 82% (120/147) of patients were considered by the MDT over 20 weeks, and in team 2, 65% (53/82) over 10 weeks. Of all GAP patients considered, 48% (83/173) were deemed eligible. Of those, 70% (61/83) were asked if they wished to attend, usually by the junior doctor leading the QI project. Thirty-six percent (22/61) of those booked into the clinic, of which 82% attended.

Substance misuse ward: Over 15 weeks, 85% (82/97) of patients admitted to the substance misuse ward were considered, deemed eligible and offered a space in the clinic at admission, of whom 15 accepted and 4 attended.

Nearly half of GAP inpatients were eligible to attend, with the total likely to be higher over time, as mental state improved. A high level of demand was demonstrated for SRH services in this population, where research also suggests a higher level of need and lower levels of access.

During weeks when the QI leads were absent, it was not recorded that any patients were considered at ward rounds or rapid rundowns. It was difficult to implement a process for this whilst the clinic was still at the pilot stage. The incorporation of a reminder into the ward round template would ensure that this is always considered.

A very high proportion of substance misuse patients were eligible for this clinic, highlighting higher levels of capacity. The main challenges for attendance were a high discharge rate, presence of withdrawal symptoms, and extensive passes off the ward.

Seclusion is a method used by mental health teams around the world to manage aggressive and disturbed behaviour in psychiatric patients in situations where there is immediate risk of harms to others.

A quality improvement project was carried out over two hospital in-patient sites containing 6 wards to see if seclusion reviews were completed safely and documented appropriately according to the guidelines set out by South West Yorkshire Mental Health Trust and the Royal College of Psychiatrists.

The quality improvement project was carried out to first audit data to see if seclusion reviews were being done to the local guidelines and standards set by the Mental Health Legislation and Royal College of Psychiatrists. This was followed by training junior doctors and reauditing date to see if any improvements were observed.

A retrospective quality improvement project was conducted assessing medical seclusion reviews carried out by on-call junior doctors between November 2022 and January 2023. Data was initially collected retrospectively spanning over a period of 4 weeks over the month of November 2023 including the analysis of 30 seclusion reviews. These results were presented as an audit to doctors and managerial staff at the end of November. Post training seclusion review data was collected over a period of 4 weeks over January 2023.

An overall improvement in 7/9 domains. The biggest improvement (54% rise) was checking for side effects and EPSEs which was only documented 4/23 times in the first pre-training run. 18% improvements were also noted for assessing and documenting if the patient had any distress or pain, clinical appearance in terms of the cardiac domains such as perfusion and colour of the skin and also their level of orientation in place person and Glasgow Coma Score.

The only two domains in which an increase was not observed was to document if seclusion should continue and justification for why this is the case. These two domains were already at 100% and the System 1 seclusion review template prompts doctors to do this at the end of the review which is possibly one of the reasons it was done well both before and after the training.

A great deal of interest and feedback was garnered and the idea was agreed that a further audit could be carried out after providing training for the current doctors and to gather post-training medical seclusion review data for comparison.

Rosewood Mother and Baby Unit (MBU) aims to provide inpatient psychiatric care to women with severe mental illness in Kent, Surrey & Sussex (KSS) in UK. Data from admissions during 2022 demonstrated discernible inequalities in admissions. A quality improvement project was undertaken to improve equity of access for admission of women with severe mental illness to Rosewood MBU, specifically, those under 18 years old, black and minority ethnicities, and across counties in KSS. The aim was to improve quality of care and patient experience for vulnerable groups across all ethnicities, not limited to their location or age.

Baseline data of MBU admissions in 2022 was collated, including demographics, age, origin of referrals, diagnosis, ethnicity, length of stay, parity, previous MBU admissions, safeguarding concerns.

The project group, inclusive of an expert by lived experience, presented the data at various network meetings and stakeholder events that helped to share information and gather experiences on barriers to referrals to Rosewood MBU, barriers for women of black and ethnic minority background accessing MBU, differences in service provisions for under-18-year-old women with perinatal mental illness in various counties.

Data for women discharged from Rosewood MBU in 2023 was collated and compared against the findings from the previous year.

In the first half of 2022, there were 20% more women admitted from Kent than Surrey and Sussex combined. This improved following interventions with a better spread of patients across counties in July–December 2023 and a 11% rise in admissions of women from Surrey and Sussex compared with Kent.

There was a greater number of ethnicities and a greater number of women from different ethnicities admitted to Rosewood MBU when comparing 2022 with 2023, and specifically across each of the 6-monthly periods. In January–June 2022, 3 women of non-White British ethnicity were admitted, compared with a 400% increase in July–December 2023 with 12 women. Overall there was 260% increase in admissions of women of Black, Asian, Mixed, White-Other ethnicity in 2023 compared with 2022. Also, in 2023, there were 2 referrals and 1 admission of a women under the age of 18, compared with no referrals in 2022.

Overall, the project demonstrates the positive impact of streamlining referral pathway, fostering collaborative working and integrating expertise from diverse professionals including experts by experience that can reduce service inequalities and improve patient outcomes.

The aim of this project is to improve the monitoring of patients on lithium under the South Gloucestershire Later Life Community Mental Health Team and to clarify the process for this monitoring with the aim of improving patient care and safety. We aim to try to achieve 100% compliance with agreed standards based on NICE and Trust guidelines.

Following a meeting with team medics we agreed a series of nine standards derived from local and national guidelines. We then used a locally held database of patients on the later life CMHT caseload on lithium therapy to identify our sample and devised a simple audit tool to collate the information. We used Rio electronic health records and ICE blood results to obtain baseline data from June 2022 to December 2022.

We used the plan-do-study-act (PDSA) cycle model for quality improvement. Following analysis of the baseline data, we planned and implemented key changes of the physical health nursing team taking over investigations from primary care and utilising a bespoke database. We also completed an education session for staff. Following these changes, data was collected and analysed from June until November 2023. From the analysis of these results, a further change was planned for PDSA cycle 2 and further data collection is planned.

Results from baseline data showed that six out of eight standards had compliance of < 60%, which included the time-sensitive investigations such as lithium levels every 3 months; kidney function tests every 3–6 months; calcium level every 6 months. Weight/BMI monitoring and documentation of side effects also had poor results. Average compliance across all standards was 57%.

Following the agreed steps to improve compliance, PDSA cycle 1 results showed improvement across the board, with average compliance increasing to 94%. Time-sensitive investigations now had 100% compliance (lithium level, kidney function, calcium level). Areas for improvement remain, namely in weight/BMI monitoring every 6 months and clear action plans for results falling out of range being clearly documented in patient notes.

By working closely with the physical health nursing team to devise a bespoke local database of information and taking over the investigations from primary care, we have shown an improvement across all standards, therefore improving the quality of care and patient safety.

Cognitive disorders, such as dementia, are a possible comorbidity and an important differential diagnosis to consider in older adults admitted to psychiatric wards with a functional disorder. Whilst cognitive assessment tools (e.g. ACE-III) and neuroimaging (e.g. MRI scans) are well established, there is significant variability in how and when they are used, which can result in inconsistences in their use. The aim was to identify the types of inconsistencies that may occur, and to provide a standardised framework in order for these tools to be used consistently on our functional rehabilitation ward.

This QIP retrospectively assessed data for all patients discharged over a 7-month period between October 2022 and May 2023, from an older adult functional rehabilitation ward. Clinical notes were reviewed to determine whether a cognitive assessment and neuroimaging had been considered, and if so, whether the assessment or investigation was appropriate and completed without delay. Correspondence to the GP or CMHT was reviewed to determine whether this had appropriate information about the relevant cognitive screening completed, and had included an appropriate follow-up plan. Data collected was checked for accuracy through screening by a second clinician, after which a consensus meeting was held to account for discrepancies.

25 patients were discharged during the 7-month period. 52% were identified as having an issue or delay in their cognitive screening and correspondence; 32% had a delay in completing a cognitive assessment; 32% did not have an appropriate follow-up plan communicated in their discharge summary regarding future monitoring of their cognition; and 8% had a delay in considering or requesting neuroimaging.

Team discussion identified that staff uncertainty relating to the use of cognitive tools and neuroimaging was a significant contributing factor to the issues identified in our results. We subsequently delivered training using a flowchart for doctors, nurses and allied healthcare professionals on the ward, which included information about the benefits and disadvantages of different screening tools and imaging modalities, in order to assist selection of the most appropriate tools on a case-by-case basis. The flowchart included the need for MDT discussion and senior psychiatrist involvement, but aimed to improve team confidence in understanding the rationale for these decisions. Based on the results of our post-intervention data, we will consider adapting the training and flowchart delivered to meet the needs of other older adult services in the trust.

To create a safe and effective induction programme for Higher Specialist Trainees (HST) at Nottinghamshire Healthcare NHS Foundation Trust.

An effective induction improves trainees' satisfaction, they feel welcomed and valued. It improves patient safety, retention, and recruitment (GMC Report 2020).

Based on GMC report, published in 2020, a survey was developed locally and data for 2021 HST induction was collected using digital platform. Initial stakeholder analysis completed, and relevant parties were invited to share the results. Two key deliverables were identified after consultation, one was a dedicated induction programme for HST which was co-produced along with trainees and stakeholders. The other deliverable was updating the induction booklet. The proposed induction plan was implemented in August 2023, the survey was repeated to the new HST cohort following induction via digital platform. Results of the survey were analysed via mixed methods (qualitative & quantitative).

The surveys conducted in 2021 and 2023 were compared and there was an increase in response rate from 50% to 64%. The domains were devised from GMC standards and assessed by if staff had received everything in the domain within a week of starting their placement and results evaluated using a t-test.

Domain A is gaining access to places and system (keys, fobs, security passes, computers, ID badges, mobile phones, IT system). This significantly improved from 27% to 88% with a p-value of < 0.001.

Domain B is physical orientation of the setting (staff facilities such as lockers, parking, library, and site layout). This significantly improved from 45% to 88% with a p-value of < 0.018.

Domain C is gaining day to day knowledge (HR, rota, annual leave, study leave, pay-roll, mandatory training, e-expenses, and guardian of safe working). There was no significant change between 9% and 19% with a p-value of < 0.48.

Domain D is an understanding of expectations (duties and responsibility during working hours, on-call, team introduction). This significantly improved from 9% to 69% with a p-value of < 0.002.

HSTs were given the chance to add comments and the responses in 2023 were more positive “excellent induction compared to previous years” compared with 2021 when HSTs felt isolated and devalued “worst ever induction in whole career in NHS”.

Overall, the results of the 2023 survey showed considerable improvement in all the key areas of induction within one week of starting the placement. Domain C demonstrates a challenge still and needs further work.