Advocacy

ANNUAL REPORT FOR JERSEY FOCUS ON MENTAL HEALTH: RE MENTAL HEALTH PATIENT ADVOCACY

Direction of Jersey Focus Advocacy

In-patient support remains the priority of the advocacy service and much of my time is spent on the ward at Orchard House. The advocacy service is available to all patients who are admitted to Orchard House. However a significant amount of work has also been carried out for individual mental health service users currently living in the community during the last 12 months. In total over 170 clients have requested advocacy help on nearly 850 occasions.

Working relationships

Working relationships with both service providers and service users continue to be excellent. Professional staff whether on the ward, in the community or senior managers, are helpful and constructive in their dealings with advocacy and are willing to listen, consider and respond to the issues raised on behalf of service users. They are also willing to help develop my understanding of mental health. Nurses and doctors on the ward appreciate the need for advocacy to maintain independence and a critical edge to challenge established or new professional practice and in turn are happy to share their expertise where appropriate. A monthly meeting has recently been introduced between the Unit Manger and the patient advocate as a confidential forum to regularly exchange information. Every two months a meeting is also to be held with the Head of Nursing, Mental Health.

Training Provision

A number of training sessions about the role of advocacy have been provided for mental health staff working in the community as part of an awareness course. These sessions have been very well received. The session seeks to inform about the role and value of patient advocacy, the importance of being able to effectively access basic Human Rights whilst detained, and to encourage staff to empathize with the fear and helplessness which can be experienced by patients on admission.

Training Received

AIMS accreditation reviewer – Royal College of Psychiatrists
Working with Mental Health Tribunals – Matrix U.K
Assessing and dealing with Capacity/Incapacity –Matrix U.K
Control and Restraint –Orchard House
Non-physical interventions – Orchard House – ongoing.

Involvement with other groups

Advocacy participates in regular meeting with the following professional and service user groups including;

Mental Health Joint Steering Group
Orchard House Patient Community Group
Advocacy worker for Mencap

In-house training sessions and ward meetings have not been taking place regularly although I attend when they do.

Legal Aid

The Legal Aid office continues to be extremely helpful and supportive, enabling fast and flexible access to legal advice for advocacy clients. Good legal representation has been provided for clients seeking support at Tribunals and appropriate representation has also been facilitated for clients with litigation, facing criminal charges, or other legal issues in the community. This link with advocacy is particularly valuable as many clients would normally find it difficult to access legal aid services by themselves.

Jersey Police

On a number of occasions the police have been contacted on behalf of, or alongside service users. This has facilitated the relationship between clients and the police, and ensured that each listens to the other’s point of view.

Advocacy has also served to inform and raise awareness amongst the Police of mental health issues including how police actions can be perceived by clients, particularly those detained and on occasion physically restrained by them.

Where complaints have been made the attitude and response from the Police has on occasion been exemplary. A letter was recently sent to the Minister of Home Affairs on behalf of a client expressing her thanks for the way in which her complaint has been investigated and the sensitivity shown towards her as a Mental Health Service User.

Citizens Advice Bureau

As a trained advisor for CAB I am able to offer clients a limited service in terms of information but refer clients to CAB for advice on detailed or complex issues. CAB has co-operated in developing a good working relationship so that service users gain access to CAB services fast and effectively.

A Training session was provided to CAB in March.

MAIN ISSUES DEALT WITH BY ADVOCACY

Medication
Home leave
Appeals against Detention and Articles

Mental Health Law- providing information for patients
Information about the Mental Health Service and clinical approaches
Complaints about; nursing staff, consultants, drug errors
Complaints about treatment in General Hospital
Complaints about treatment by the police
Support at Ward Rounds
Requests for second opinions or change of psychiatrist
Access to activities
Range and timing of activities
Human Rights – incapacity advocacy
Dietary requirements

(issues dealt with)

Employment – loss of job, unfair treatment, liaising with employers
Debt management, bank charges
Criminal charges
Removal of children by Children’s Service
Visitors to ward
Access to services in the community
Home assessment for elderly clients

In-house community meetings

Advocacy participates in community meetings held in Orchard House every other Thursday. This is a valuable opportunity for patients to express their views on the practical running of the ward. Wide ranging topics raised by patients include activities and outings, quality and variety of food, air-conditioning, access to drinks and smoking during the night, use of mobile phones, cleanliness and the need for all to work together in keeping the ward tidy.

Mental Health Tribunals

A great deal of time and effort has been spent on seeking to influence the improved delivery of Mental Health Tribunals. As a result of advocacy input the demand for Tribunals has greatly increased. A meeting was held in March of this year with the full range of professionals involved to discuss advocacy concerns and since then significant progress has been achieved as follows;

Time delays;

The most important progress has been achieved in the time taken for an appeal to be heard by the Mental Health Review Tribunal. This has dramatically reduced from 22 weeks to 4-6 weeks. This helps ensure that the process is Human Rights compliant and is so much better for patients.

Reports;

The in-patient Consultant Psychiatrist has been very prompt in producing written Medical Reports which allow patients and their representatives to prepare more quickly and keeps the process on track.
A significant step forward has also been taken by Nursing Staff who have responded to my request to produce written reports - these follow a template provided by the MHRT in the UK and provide valuable up-to date information to the Tribunal, again allowing the patient and his/her representative to prepare for the Review.

3. Legal Representation;

The Acting Battonier has been most helpful in ensuring that, where requested, a legal representative is appointed immediately. So far patients have been allocated lawyers who have been able to establish a rapport with patients, acted promptly, and are developing awareness and skills in this area.

(issues dealt with)

There is still a need to educate legal representatives from a variety of firms and hopefully this will be addressed.
Guidelines for legal representatives – I have produced a draft which has been reviewed by a lawyer, a psychiatric social worker and the Director of Mental Health. This draft is currently with the Chairman of the Tribunal for comment. The Draft attempts to address the requirements in Jersey whilst being largely based on the UK Law Society Guidelines.

4. Training;

The committee of Jersey Focus has kindly agreed to provide funds for a one day training course. This will be provided in Jersey by UK professionals who have extensive experience of working with Mental Health Tribunals.
All Tribunal panel members, medical and social work professionals, legal representatives, mental health service managers and administrators will be invited to attend.
The intention is to ensure a greater understanding of the principles and process, the impact of ECHR on Jersey legislation, and improving local practice. The course will be tailored to be of benefit for all concerned and will involve group work.
I have discussed with the Director of Mental Health the desirability of all panel members having the opportunity in the near future to visit Orchard House and Clinic Pinel so that they are updated about the facilities and services provided.

Patients’ views re Mental Health Tribunals

Most importantly patients who have applied to the Tribunal, including those who have been unsuccessful, have so far all told me that they found the Review process to be respectful and useful. Detained patients have valued the opportunity to challenge medical opinions, have their views listened to, and to express their concerns. Patients who have not been released from their articles never the less claim a sense of empowerment from having a Review. Whilst they may not agree with the panel they are respectful of the decisions made.

I would therefore like to emphasise that the review process is, from the patients’ perspective, by no means a waste of time or toothless. Patients greatly value having the right to be heard by a panel – it restores their sense of dignity and from the very start of the appeal process removes the terrible sense of helplessness many experience.

DEVELOPMENTS SINCE LAST REPORT

AIMS

Orchard House has received full accreditation from the AIMS programme through the Royal College of Psychiatrists and is now one of only twelve acute mental health in-patient wards in the whole of the British Isles to have full accreditation.

This is a national award developed by the Royal College of Psychiatrists for which rigorous standards and criteria must be met on all aspects of ward policy and practice. The purpose is to improve the quality of acute inpatient wards and the standards have been developed from a literature review and in consultation with stakeholder groups. This is therefore a significant achievement, and one of which the staff are rightly proud. The standards are reviewed each year in self and external peer review by Aims accredited reviewers.

Health Care Commission

The Healthcare Commission has identified adult acute inpatient service provsion as a priority on which to focus a service review. The HCC have developed a national standards framework by which to assess the quality of care and Orchard House is being assessed inline with other psychiatric units in the UK.

Data has been collected in the following ways:

a questionnaire for trust acute inpatient leads
a questionnaire for ward managers - to be completed for each relevant ward
a questionnaire for service user groups - to be completed for each relevant ward
an audit of care records - to be completed for a sample of 50 care records

The assessment, which is all evidence based will be completed later this year. The results will be transparent and will be pubished by the HCC in January 2008 on the internet.

Handbook

The Handbook requested in last year’s report has been produced and is readily available to all patients. It can be easily updated and covers all the basic practical information about life of the ward.

Plain English law

Explanations of the most relevant parts of the Mental Health Jersey Law are now given in the Handbook in plain and easy to understand English.

(developments)

Weekly meetings with consultant

The consultant responsible for patients in Orchard House carries out ward rounds three times per week and sees patients on a weekly basis. As a matter of routine the consultant now advises the advocate as to which patients he intends to see as soon as he is on the ward after the completion of Multi Disciplinary Team Reviews. This means that the advocate can accompany patients if they so wish.

Patients have additional meetings with SHOs as and when required during the week.

Incapacity advocacy

I have received training in Incapacity Advocacy in the UK and can now act as an Independent Mental Capacity Advocate in line with the UK Mental Capacity Act 2005.

Smoking

U.K hospitals introduced a no-smoking policy at the beginning of the year. In Jersey as patient advocate I successfully argued that both a smoking room and a cigarette machine should be retained at Orchard House. Many psychiatric patients are addicted to smoking and whilst they accept that this is a habit they should give up they do not believe it is appropriate to force them to so at a time of their greatest distress and vulnerability. In the same way patients who have been detained under Articles of the Mental Health Law are not permitted to leave the ward. They do not wish to be dependent on staff or friends to bring in cigarettes – indeed patients firmly believe that the ability to buy cigarettes as and when required remains one of the few things they are able to choose to do whilst locked within the acute ward. A pragmatic solution in line with patients’ wishes was achieved.

Mixed Ward

In the UK tremendous pressure is being applied for all psychiatric wards to be single sex. This issue is therefore regularly discussed with individual and groups of patients in order to ascertain whether they are comfortable with the mixed ward approach on Orchard House.

To date the response has been unanimously in favour of a mixed ward. Comments can be summarised as follows;

A mixed ward provides a more normal environment
The male patients demonstrate less tension and less aggressive behaviour
No issues of safety or inappropriate behaviour appear to have arisen
The female patients do not feel vulnerable either on the ward in the day time or in their rooms at night

A review was carried out earlier this year by the ward sister who looked at the incident reports and established that the level of inappropriate behaviour actually is less now that the ward is a mixed sex environment. ICU facilities are of course available for patients who are sexually disinhibited.

Visitors to Wards

Many patients expressed concern about the number of visitors on the ward throughout the day. As a result visitors are now encouraged to respect visiting times where possible to enable in-patients to make the most of the therapeutic environment. Visitors are also required to sign in as they arrive and leave the ward.

ISSUES WHICH ARE ONGOING:

The following are issues which will hopefully be addressed by the managers and staff on behalf of clients in the coming year. I am confident that the team will continue to demonstrate how they work well together to improve services for patients.

Availability of Mental Health Tribunal Panel Members:

The Mental Health Tribunal administrator does struggle to find panel members causing delay to the review process. Consideration needs to be given as to whether the availability or number of panel members needs to be re-assessed in view of the appropriately increasing use of the Review process. It should also be possible to schedule tribunals in advance on a monthly basis so that members, and reserves, are always available.

Article 6 Appeals

These remain a matter of concern. In the recent prolonged absence of the former Minister of Health it proved extremely difficult to provide a Review within a reasonable time frame. Further, it can be questioned whether the law in this area provides a process which is potentially unfit for purpose. The Director of Mental Health has written to the Solicitor General to request advice as to whether the law in this area is compliant with the European Convention on Human Rights.

Forcible medication whilst on Article 6

With regard to supplementary treatment whilst a patient is on an Article 6 it is important that proper detailed advice is obtained about when and how frequently this can be applied both for the protection of patients and staff. It is also essential that communication should be clear and up to date between staff on the ward so that those making a decision to forcibly medicate are aware if this has already been carried out on the patient.

Intensive Care Unit

The intensive care suite has on occasion been in use for prolonged periods of time for very unwell individual patients requiring 2:1 nursing care. Whilst other in-patients understand the use of ICU they point out the direct negative impact that they believe this has on them. Where during the course of a shift a rotating 2 members of staff are constantly in ICU other patients are not given the level of nursing care and valuable individual input they could otherwise

(issues ongoing)

expect. Patients comment that "the nurses are doing their best" but the lack of staff remaining on the main ward makes it impossible for the normal routine to be maintained. On occasions when the ward has been busy in this way patients have reported feeling intimidated by other patients and this increases their feelings of anxiety and tension.

Damage in ICU

Security and recent damage to the fittings in the ICU unit are of concern. A very unwell patient was able twice to successfully break out of seclusion. Further, the patient was able to cause significant damage to fittings in ICU placing both the patient and members of staff at risk, with potential long term consequences for the patient once recovered.

Damage and violence on the ward

Patients have complained that they were unaware that assaults on staff and or damage to the ward will not be tolerated on the unit until after they had actually committed such acts. Some patients have been very surprised to learn that they would be held accountable and possibly charged for actions of this nature. It would seem reasonable that patients are consistently made aware of the ward policy about facing the consequences of their actions very early in their admission.

Community Team Support

Clients who have long standing relationships with Community Psychiatric nurses or community support workers have complained that these relationships are too often suspended whilst they are receiving treatment in Orchard House. Many clients would welcome regular on-going visits from their CPN whilst in Orchard House; the view is often expressed that this would help them see a continuity of care. Clients have also expressed the wish to be taken on trips out of the ward by their CPN particularly, but not only, when ward staff are too busy to do so.

Alternative Facilities

From both patient comment and observation there appears to be a lack of appropriate facilities for certain difficult to manage patients including those suffering from advanced Korsakoff’s,learning Disability, or long term schizophrenia for whom in-patient care on an acute ward appears to be inappropriate.

Provision and use of Therapeutic Activities

Throughout last year many patients have complained that the provision of activities is poor. Those who do participate value the activities provided and are positive. However a recurring complaint is that activities are limited to the working day with still nothing available in the evenings or weekends. Patients are very keen to see a more imaginative range of activities which responds to individual interests and addresses the needs of the current client group. Whilst excellent facilities are provided these are under-used and for much of the day stand empty. More significantly they do not feel integral either to the ward, or to the Treatment Plans for individuals. The involvement of nursing staff in actively encouraging participation appears to be limited. Whilst ideas are regularly floated by patients at Community Meetings little progress is visible in terms of patients being offered "normal" weekend activities such as DVD/film nights, barbecues, etc.

Patients have also requested more group work or activities associated with daily living, such as Assertiveness training, Anger management, and budgeting skills.

Alternative therapies are also often requested.

The recent appointment of a confident and enthusiastic Occupational Therapy Assistant has been welcomed although, as the hours are restricted to 25 per week, it is difficult to see how this is sufficient to meet the many needs identified by patients.

Alarms

There is a lack of any form of alarm system which works on the activity wing where the advocacy office is based. This leaves staff working on the wing, often alone, in a vulnerable and uncomfortable position and is clearly unsatisfactory from a risk management perspective.

Outpatient referrals

Very few if any referrals are received or contact initiated via the Psychiatric out-patient clinics or community support workers. It would be a positive development if the wider services also played a part in making the role and availability of advocacy known to mental health clients.

OVERVIEW OF IN-PATIENT CARE

I believe that the in-patient mental health service provision in Jersey continues to be of a very high standard. Whilst staff have faced a number of difficult issues and pressures over the last 12 months they are clearly committed to improving patients’ health and have sought to provide and maintain excellent professional care. Even when severely tested all, in particular nursing staff, have done their utmost to maintain high standards of clinical and personal care, whist considering and respecting the needs and dignity of each individual. The high quality and the attention to detail of the Orchard House environment is greatly appreciated by patients and their families, and is almost daily described as reflecting respect and support at a time when they feel at their most vulnerable. The positive relationships between staff and patients are evident and are highlighted below - these comments reflect the vast majority of views expressed.

Patients’ comments about the ward on discharge questionnaires;

Nearly all boxes covering the environment, nursing care and standards of the service provided for in-patients have been ticked as excellent or very good, with individual comments reflecting this as shown below;

"Exceptional help"

"A very well run service"

"Reassurance, support and encouragement, help to recover"

"Wise, respectful of my condition/personality"

"All staff extremely approachable"

"I felt cared for"

"A very positive experience"

Comments re Advocacy from patients’ discharge questionnaires;

"The patient advocate put me at ease, reminded me of things I forgot and wanted to ask the consultant"

"Friendly, caring and very helpful"

"Provided me with very useful information to enable me to continue further treatment"

"Upfront, intelligent, respectful, thorough"

"Friendly and efficient"

Of 23 questionnaires 18 patients described themselves as "Very Satisfied" and 5 as "Satisfied" with the advocacy service and all but 1 would recommend it to others.

Advocacy aims to provide you with support for any issues that you may have in order that your voice can be heard and your needs met.

Advocacy is about:

Stating a case
Influencing decisions
Ending assumptions
Getting better services
Being treated equally
Being included
Redressing the balance of power
Being able to exercise your rights.

Advocacy is a process of working towards natural justice. It is a free, confidential, independent and easily accessible service.

An advocate will act as an ally and when requested will "stand in" for the person they represent. The advocate will not at any time "take over" the situation: they will simply ensure that your point of view has been expressed and understood.

How Advocacy can help you:

If you are detained under the Jersey Mental Health Law.
If you are under Guardianship Order.
If you are Subject to Curatorship.
To make an appeal to the Mental Health Review Tribunal.
To make a Complaint.
At Ward Round & Review Meetings.

Advocacy is designed to help you with :

Understanding what your rights are.
Communicating with mental health staff and other professionals.
Ensuring you have enough information about your care and treatment
Ensuring you have enough information about the article you may have been detained under, and what this means in practice.
Explaining how, and to whom, you can appeal against detention.
Planning your care package.
Putting you in touch with other specialist services.

What Advocacy is not ?

Legal advice
Befriending
Counselling
A substitute for making existing services more accessible, acceptable and effective.

The advocate, Patricia Winchester, can be contacted by ringing 07797 716447 and leaving a message, or by asking the staff on the ward at Orchard House to contact the advocate.

Appendix 1 : Information about Advocacy for Patients and Service Users

Jersey Focus on Mental Health provides a free, confidential and independent advocacy service for people with mental health difficulties.

Advocacy will help you make sure your voice is heard in whatever context is appropriate for you. They will support you at informal or formal meetings, hearings, assessments and reviews.

The advocate will ensure that you are aware of your rights, and help ensure that your rights are respected.

The advocate will support you to speak for yourself, or will speak on your behalf. If you want the advocate to speak on your behalf s/he will spend time with you beforehand making sure they understand what you want, and ensuring that they say only what you want them to say.

The advocate will not make any decisions or choices on your behalf unless they have your permission. You remain fully in control of any agreed action, and will be kept fully informed at all times.

The advocate will discuss and explore with you the various options facing you, and will attempt to provide full and balanced information so that you can make informed choices.

The advocate is bound by a strict code of confidentiality, and will not divulge any information about you unless they have your permission. However confidentiality may be broken if the advocate fears that there is a risk of significant harm to yourself or others, or that you are engaged in criminality. In any case they would make every effort to discuss it with you before taking any action.

You have the right to stop any action, at any time.

The advocate can be contacted by ringing 07797 716447 and leaving a message, or by asking the staff on the ward to contact the advocate.

Appendix 2 : Jersey Focus on Mental Health: Confidentiality Policy

Confidentiality is one of the fundamental principles of the Advocacy service. Jersey Focus on Mental Health Advocacy offers confidentiality to all clients and nothing learned by the advocate will be passed on to anyone outside the service without your express permission.

Your advocate will not discuss you or the information you have given with anyone outside Jersey Focus unless you have given them permission to do so.
Information about a client will not be shared or discussed with another agency, or with other professionals, relatives, friends, other clients or anyone else without the express permission and consent of the client.
All referrals are made with the knowledge and consent of the client.
Any records or documents we have about you will be kept for five years from our last contact with you before being destroyed. If your contact with us lasts for longer than five years, we will review your file annually with you and remove any information you believe to be inaccurate or irrelevant.
We will not keep any information you give us about a third party or from a third party unless it is essential to your case. A decision about how this is done will be made between you and your advocate. Where Jersey Focus thinks it is necessary to keep some of this information, then your advocate will sit down with you to decide the most appropriate means of doing this. You will be asked to indicate your agreement to this by signing a consent form.
All records maintained by the advocate will be available to the Director of Jersey Focus and will be surrendered to the Director on termination of association with Jersey Focus.
Any problems with any part of this policy should, in the first instance, be referred to the Director of Jersey Focus and then to the Executive Committee.

There are exceptions to our confidentiality policy.

The only circumstances where a breach of confidentiality will be considered are:
There there is a danger to clients or others
When not to do so would be breaking the lawIn any case the advocate will make every effort to discuss it with you before taking any action.
Where members of the management committee/Board require access to client records e.g. to investigate a complaint, a Declaration of Confidentiality will be signed. In this case, it will have a "limited life" of 3 months.