Culture is everything: reflections on reducing restrictive practice at Lesney Ward

Restrictive practices are techniques such as physical restraint, seclusion and rapid tranquilisation used to limit a person’s liberties, movements or freedom to act independently in potentially dangerous situations.

The inappropriate or overuse of restrictive practice in mental health services has been identified as an area of concern in healthcare since at least 2015.

Beginning in 2021, the Health Innovation Network has been involved in local efforts to reduce restrictive practice based on the findings of a successful pilot led by the National Collaborating Centre for Mental Health.

We speak to HIN Patient Safety Project Manager Ayobola Chike-Michael and Ward Manager James Njoki about the programme team’s recent visit to Lesney Ward, an acute adult mental health ward which is part of Oxleas NHS Foundation Trust. Read reflections from previous visits here.

Ayo

In my role of supporting mental health wards to reduce restrictive practices in south London, I recently had the privilege of visiting Lesney Ward, which is part of Oxleas NHS Foundation Trust.

Lesney is a 20-bed mixed adult mental health inpatient ward, and I was eager to explore the ward’s efforts to create a therapeutic environment with minimal use of restraints.

Upon arrival, I was delighted to find that Lesney Ward had recently undergone refurbishment. The ward now boasts a fully functioning gym, a sensory room and therapeutic garden among other enhancements.

During my visit, I met the ward manager, two other members of staff and a QI lead from the Trust. Engaging in meaningful discussions, we exchanged ideas on how to promote positive change and minimise restrictive practices within the ward.

One remarkable aspect of Lesney ward is its commitment to establishing a culture of no restraint as the default approach. As a result, the ward does not have any seclusion rooms. The primary method used to reduce the use of restrictive practice is the de-escalation method, which was commended at a CQC inspection in February 2023.

I was impressed by the variety of successful de-escalation methods employed by the ward. Apart from the verbal de-escalation methods, there were other successful change ideas the team shared with me:

• Patient Engagement Time (PET). PET is a 7-day activity timetable with flexibilities where each staff spends 30 minutes with their assigned service user to build rapport and provide reassurance.
• Daily community meeting. Held Monday to Friday, this meeting involves patients, staff, healthcare assistants, occupational therapists, activity coordinators and others. This could be led by patients or staff.
• Relational security. The ward makes active use of the ‘See Think Act’ framework.
• Simplification of language. For example using terms such as ‘physical health check’ instead of ‘vital signs’, which enhances communication between staff and service users.
• Being proactive about giving information to service users.
• Diverse activities. Activities on offer include arts and craft, walking group, sensory group, therapeutic garden visit, orientating to ward, gym induction and physical health competency.
• Appropriate interventions and medications. Ensuring patients receive the right interventions and medications to prevent transfers to psychiatric intensive care units whenever possible.
• Inclusive safety huddles. These huddles involve all stakeholders including domestic staff
• Nutritious food. Food is sourced from reputable providers, with careful planning going into making sure that it provides the right nutrition for service users. Taster sessions were organised for both staff and service users, and a variety of fruit is available throughout the week.
• Promoting decaffeinated beverages while maintaining flexibility
• De-escalation for smoking demands. Employing de-escalation techniques to address service user requests to smoke, directing them to e-cigarettes.

My visit to Lesney Ward was an inspiring and enlightening experience. The recent refurbishments have enhanced the ward’s facilities and contributed to a more holistic approach to care.

The ward’s commitment to creating a therapeutic environment with minimal use of restraints is truly commendable. By prioritising patient engagement, promoting positive change, and implementing innovative strategies, they show us the possibility of creating a mental health system that values dignity, respect and recovery for all.

James

The culture of doing everything we can to deliver the best care at Lesney Ward is something that is quite special; it is something that predates my time here but which every staff member believes in.

We take a lot of pride in having very low levels of restraint and very rarely needing to refer our service users to Psychiatric Intensive Care Units (PICUs).

Whilst developing a culture takes years, we hope that our service users feel the benefits of our culture as soon as we start caring for them.

We are big believers in starting things off on the right foot. We make sure that all the people entering our care have their medicines reviewed as soon as possible, and we spend time with service users helping them get oriented to the ward and understanding the support we can offer them.

We hope that this helps us build bonds between service users and the staff and helps everyone to understand that we want to do everything possible to support our service users.

In the longer-term, having such a proactive culture has meant that we have been able to improve the environment we provide care within, which in turn has meant better outcomes.

Where it might have been easy for our old gym to have quietly closed when it fell into disrepair, the attitude of the team here meant that we saw it as an opportunity for improvement. Now, the gym is better than ever, and it provides a positive space for our service users.

Likewise, our garden is something that people might dismiss as being a bit of a luxury – in today’s NHS how can you justify spending time and money on greenery?

The reality is that those small things, those moments of going above and beyond the basics, can make a big difference to health outcomes and reduce the need for restrictive practice.

For example, a few weeks ago we had a new service user who was very unwell. It was very difficult for us to safely provide the care he needed as he was distressed about his new surroundings. It would have been an easy option to “escalate” this service user to PICU.

However, through going through the records of the service user, we found that they had an affinity for being outside. We tried moving some of our time with them into our garden, and we saw a huge transformation.

That sort of outcome isn’t something that comes from a moment’s work, or even a month’s work. But it shows that persistence and creating the right culture will pay off in the long term. From the first step to the last step, make sure every one has the right intention!