Low Secure Services Research Articles

Use of Formulation Information Risk Management in Low Secure Services: An Audit Project

AimsRisk assessment is a key component of patient care in forensic psychiatry. This audit aimed to measure the completion of different aspects of the Formulation Information Risk Management (FIRM) risk assessment for patients in the care of Low Secure Services. The FIRM incorporates formulation and a care plan into the risk assessment and should be completed for all inpatients in the trust. It was hoped that this audit would help identify any areas of improvement required in the completion of this risk assessment, and provide recommendations that would contribute to improving standards where required.MethodsData were collected on 23rd December 2021 from the electronic patient records of 37 inpatients at a Low Secure Services Unit in Northern England. 5 audit criteria were devised following review of the trust standards regarding the completion of the FIRM assessment. These criteria included the completion of the Current / Historical Risks section, Formulation and Staying Safe / Staying Well Care Plan aspects of the assessment. It also assessed patient involvement in completion of the assessment and whether the assessment had been updated in the last Care Programme Approach (CPA) period. The findings of the audit were presented at a local academic meeting and were distributed to the relevant staff.Results100% of patients had the Current / Historical Risks section completed89% of the patients had the Formulation completed73% of patients had the Staying Safe / Staying Well Care Plan completedIn 16% the service user had been involved in the risk assessment completionIn 70% of cases the FIRM had been updated since the last CPA (or in the last year if not applicable)ConclusionCurrent / Historical Risks section completion rates matched expected trust standards. Significant improvement was seen in completion of the Formulation and Care Plan compared to auditing done in October 2021. There was room for improvement regarding increasing patient involvement in the completion of the risk assessment, often due to it being completed at night leading to the patient being unavailable. It was recommended that the FIRM should be more consistently reviewed and updated as part of each patient's 6 monthly CPA review. A re-audit would prove useful to monitor the progress of these measures, and the scope of a future audit could also be widened to include the timeliness in which the FIRM is completed for new patients.

Attention Deficit Hyperactivity Disorder in a Male Medium Secure Unit

AimsThe worldwide prevalence of Attention Deficit and Hyperactivity Disorder (ADHD) in the adult population is estimated to be 2.5%. Prevalence studies have shown rates to be consistently around ten times higher in the prison population, but there is less known about secure psychiatric hospital populations. ADHD has relevance as a predictor for offending, for challenging behaviours when incarcerated, for lower quality of life and high costs for both the NHS and prison systems. This service evaluation aimed to establish estimated prevalence of ADHD within one male medium secure unit.MethodsA cross sectional review of computerised medical records for all service users on the male medium secure forensic unit took place, to identify those who met inclusion criteria. Service users who were too acutely unwell or had an established or pending diagnosis of ADHD were excluded.The Brief Barkley Adult ADHD Rating Scale (B-BAARS), a 5 minute screening questionnaire, was given to service users to complete. Anonymised responses were converted to electronic format and the compiled results analysed.ResultsThere were 125 service users at the time of information gathering, with 112 eligible according to inclusion and exclusion criteria. 2 of the excluded service users already had an ADHD diagnosis. 70 service users out of those approached, agreed to take part in the screening (62.5%). 2 out of 70 (2.9%) service users met criteria for a possible diagnosis of ADHD.ConclusionUsing the B-BAARS, 2.9% of service users on the male medium secure forensic unit reported clinically significant symptoms suggestive of a diagnosis of ADHD. This estimate is significantly lower than other studies in prison settings. When combined with the figure for service users with a pre-existing diagnosis, however, the figure is still higher than in the general population (5.5% compared to 2.5%), and illustrates that screening tools can have a useful function in forensic settings.There may have been methodological issues with this evaluation, including the self-reported nature of symptoms, the comparatively high level of functioning required to complete the questionnaire and the low response rate amongst the service users.This evaluation serves to increase awareness about ADHD in the forensic population in general. It also highlights the value of this simple screening tool, or one similar, to clinical teams on the forensic wards. The screening tool could be further utilised in low secure and women's services to establish if results are similar amongst these populations.

Integrated balancing approach for hosting services with optimal efficiency - Self Hosting with Docker

With the emergence of giant corporations that provide cloud services and gaining a monopoly over the market, the increasing need for low cost and secure services for hobbyists of industry level projects can be satisfied by using self-hosting the cloud services rather than cloud-hosted services. As cloud service architecture is less flexible and less secure in terms of performance due to its underlying approach in its infrastructure, a self-hosted service looks more adequate for this manner. This paper implements the use of hosting services with an addition of Docker and Nginx platform, a way to prevent the mentioned instances with additional capabilities giving the user more freedom and flexibility. Docker in Portainer is used to contain more containers in a single Raspberry Pi, without which each container requires separate devices.

A national census of forensic in‐patients with intellectual disability and five‐year follow‐up

AbstractA national census was undertaken for the first time to establish number of patients with ID in secure forensic in‐patient services in Scotland and identify their treatment needs. All forensic mental health units were identified and contacted with a request to contribute. Response rate was 100%. Initial results in 2013 revealed 89 patients with ID, 83 male and six female. This group contributes to 17% of the overall forensic in patient population (n = 522). A higher proportion are from the North of Scotland. Key characteristics include an average age of 22 at first admission, history of violent offending, drug and alcohol abuse and self‐harm. Patients with ID in high secure services had significantly higher risk and total Historical Clinical Risk‐20 scores than those in a lower level. A range of significant health needs were identified enabling clinicians to build a profile of the population. A variety of medical, psychological and occupational interventions were utilised. Delivery seemed consistent across services, although poor recording made accurate assessment difficult. Nine percent were re‐admitted to a higher level of security within a 5‐year period (2013–2018). Repeated annual census findings revealed a slight decline in in‐patient numbers over a 5‐year period, although the proportion of ID patients (17%) remains constant. Data for 2018 indicate 85 people with ID, from a total in‐patient population of 490; female population increased to 10 (12%). Forty one (46%) patients either moved to a lower level of security or were discharged to community within a 5‐year period, indicating treatment success. This census provides unique evidence highlighting modest numbers of patients with ID, the majority of whom are cared for in low secure services. The populations' needs are considerable, but it is unclear if individual needs are being addressed. This requires further exploration, as does efficacy of interventions, in order to address the burden of psychological morbidity.

Predictors associated with readmission in low secure forensic settings in the UK: an exploratory investigation and survival analysis

ABSTRACT Readmission from secure forensic services has significant implications for individuals and providers. Whilst there is research on readmission for forensic services internationally and for medium secure services in the UK, little is known about rates of readmission to low secure services, and there is no research examining predictors of readmission in low secure services specifically. This study aimed to examine rates and predictors of readmission of 94 individuals discharged from UK-based low secure services. A retrospective quantitative design was employed to assess the rate of readmission. Treatment, demographic, clinical and forensic factors were considered to compare readmitted and non-readmitted groups and examined as possible predictors of readmission. In total, 34% patients were readmitted with an average time to readmission of 524 days. Readmitted patients differed significantly from non-readmitted on prescribed antipsychotic medication, previous forensic admissions, psychology intervention and group psychology intervention. Previous secure forensic admissions, scoring present on HCR-20 historical problems with violence and employability were significantly associated with a shorter time to readmission. Deterioration in mental state was the most common reason for readmission. Time to readmission post-discharge from low secure services can be predicted by several factors that are readily available to clinical teams. This novel exploratory investigation is imperative in furthering understanding of factors associated with readmission to LSFS.

National Survey of Psychiatric Intensive Care, Low Secure and Locked Rehabilitation Services: NHS patient characteristics

Aims: To update the benchmark from the 2006 National Survey, comparing users of NHS psychiatric intensive care (PICU) and low secure (LSU) services, and to define 'locked rehabilitation' (LRU) patient characteristics.<br/> Method: A cross-sectional census day questionnaire (November 2016) with a six month follow-up ending in May 2017.<br/>Results: 104 NHS units responded: 73 PICU, 644 patients; 17 LSU, 190 patients; 14 LRU, 183 patients. The typical PICU patient is younger, employed, stays for shorter periods, is more likely to suffer delayed discharge and mood disorder, have complex needs, have had mental health admissions in the last 12 months, be on 1:1 or higher observations, and have fewer antipsychotic and physical health medications but more benzodiazepines. The typical LSU patient is an out of area transfer, least likely to have been admitted for self-harm or non-concordance, and is of Black Other ethnic origin. The typical LRU patient is less likely to be married or have a long-term partner, has the lowest complex needs, but is most likely to have had physical examination and investigations.<br/>Discussion: There has been a rise in PICU and LSU patients from the Black and Minority Ethnic (BAME) population. Length of stay (LoS) for PICU and LSU patients has doubled; there are lower rates of delayed transfers of care.<br/>Conclusions : Our findings demonstrate that PICU and LSU services are providing care to the right patients as they were conceptualised in national guidance, and provide a benchmark for LRU patients.

Service user experiences of risk assessment and management in a low secure service

ABSTRACT Risk assessment and management are core features within forensic services. With the implementation of recovery principles, there has been more investment in adopting collaborative approaches in this process. This paper explores five service user perspectives of collaborative risk assessment and management within a low secure service. Semi-structured interviews were analysed using Interpretative Phenomenological Analysis which produced two superordinate themes: ‘Snakes and Ladders’ and ‘Knowledge is Power’. Although there have been positive experiences of collaborative risk, more work needs to be done to develop collaborative working throughout the risk process. The findings are consistent with the forensic literature. Clinical implications and directions for future research are discussed.

An exploration of MDT views on key factors to consider when determining a service users required level of security

Purpose The purpose of this paper is to identify what key factors multi-disciplinary teams (MDT) deem as most important when making the decision to move service users from one level of security (including low, medium and high secure services) to another. The researchers used the findings from this study to further develop a tool; the assessment for level of security tool (ALS), which aims to structure and streamline this decision-making process. Design/methodology/approach Data from 18 interviews (MDT staff) were analysed using the Delphi technique (Dalkey and Helmer, 1963). This revealed a range of factors discussed when considering service users moves. Participants were asked to rate these factors in accordance with the Delphi which resulted in the removal of certain less important factors based on their scores. The researchers then compared these factors of relevance with a checklist of 16 items previously proposed by a consultant psychiatrist within the trust. This comparison allowed the researchers to highlight any similarities and differences present. Findings Findings from staff interviews revealed a range of 20 clinical factors perceived as essential to this process including procedural, relational and physical security aspects. However, variations were evident between the MDT priorities (20 items) and the originally proposed list. This emphasised the need for a tool which facilitates a holistic and streamlined approach. Practical implications The findings from this research have resulted in the development of the ALS tool comprising of 18 key factors. Originality/value It is envisaged the development of the ALS tool will not only facilitate and structure the decision-making process but also ensure a person-centred approach. This is because the ALS allows for a holistic approach based on an array of factors deemed important to that particular service user. Furthermore, the ALS tool contributes towards the paucity of published structured professional judgement tools needed to make such decisions.

Impact of a peer-review network on the quality of inpatient low secure mental health services: cluster randomised control trial

BackgroundPeer-review networks aim to help services to improve the quality of care they provide, however, there is very little evidence about their impact. We conducted a cluster randomized controlled trial of a peer-review quality network for low-secure mental health services to examine the impact of network membership on the process and outcomes of care over a 12 month period.MethodsThirty-eight low secure units were randomly allocated to either the active intervention (participation in the network n = 18) or the control arm (delayed participation in the network n = 20). A total of 75 wards were assessed at baseline and 8 wards dropped out the study before the data collection at 12 month follow up. The primary outcome measure was the quality of the physical environment and facilities of the services. The secondary outcomes included: safety of the ward, patient mental wellbeing and satisfaction with care, staff burnout, training and supervision. We hypothesised that, relative to control wards, the quality of the physical environment and facilities would be higher on wards in the active arm of the trial 12 months after randomization.ResultsThe difference in the primary outcome between the groups was not statistically significant (4.1; 95% CI [− 0.2, 8.3] p = 0.06). The median number of untoward incidents rose in control services and remained the same at the member of the network (Difference between members and non-members = 0.55; 95% IC [0.29, 1.07] p = 0.08). At follow up, a higher proportion of staff in the active arm of the trial indicated that they felt safe on the ward relative to those in the control services (p = 0.04), despite reporting more physical assaults (p = 0.04). Staff working in services in the active arm of the trial reported higher levels of burnout relative to those in the control group. No difference was seen in patient outcomes.ConclusionsWe did not find evidence that participation in a peer-review network led to marked changes in the quality of the physical environment of low secure mental health services at 12 months. Future research should explore the impact of accreditation schemes and examine longer term outcomes of participation in such networks.Trial registrationISRCTN79614916. Retrospectively registered 28 March 2014.

Outcomes in a low secure unit: pre-admission and post-discharge comparisons

ABSTRACTEmpirical research seldom reports on clinical outcomes within low secure services. By comparing outcome measures prior to admission and following discharge this study aimed to investigate the care pathways of patients admitted to a low secure unit (LSU). The study was conducted in an LSU and consisted of 70 patients (54 male, 16 female). Data were collected retrospectively and analysed in relation to placement security (upon admission and discharge) and admissions to hospital. Results revealed that admissions to hospital and time spent in hospital decreased post-discharge in comparison with pre-admission. Forensic patients were found to have fewer admissions than civil patients prior to LSU admission. Some differences were also observed within gender and Mental Health Act (MHA) section status for placement security. The findings demonstrated that following treatment in a LSU, care pathways may be less restrictive than prior to admission. Further, more robust research on the outcomes of LSUs is required.

Staff support procedures in a low-secure forensic service

PurposeStaff working in forensic inpatient settings are at increased risk of harm perpetrated by patients. Support offered in response to such incidents can have a significant impact on how staff recover. The purpose of this paper is to explore how staff support procedures implemented in one low-secure forensic service impacted on staff recovery.Design/methodology/approachIn total, 11 members of staff who had direct patient contact volunteered from an opportunity sample. Semi-structured interviews were conducted with each participant, asking about experiences of abuse at work and subsequent staff support procedures. Interviews were analysed using thematic analysis.FindingsFour overarching themes were identified; experiences of harm, supported recovery, missed opportunities and therapeutic relationships. This led to a better understanding of how staff coped with incidents of abuse at work and how support procedures impacted on their recovery.Research limitations/implicationsThe service evaluation was limited by transferability of the findings. The process of sampling may have meant there were biases in those who volunteered to take part. Further projects such as this are required to develop the themes identified.Practical implicationsFindings led to the development of a new integrated model of staff support.Originality/valueThis was one of the first studies in the UK to formally evaluate a staff support procedure in forensic low-secure services and include experiences of both clinical and non-clinical staff who are regularly exposed to potentially harmful events.

The prevalence of constant supportive observations in high, medium and low secure services.

A small number of individuals accounted for a disproportionately large proportion of CSO hours in each setting. Adverse incident rates were higher on CSO than when not on CSO. There was considerable variation between different settings in terms of CSO use and the reasons for commencing CSO. Clinical implications The study describes the prevalence and nature of CSO in secure forensic mental health services and the associated organisational costs. The marked variation in CSO use between settings suggests that mental health services continue to face challenges in balancing risk management with minimising restrictive interventions. Declaration of interest A.B. and J.L.I. are both directly employed by the NHS trust in which the study was conducted.

Recovery in a low secure service

This empirical paper describes a study that explored the lived experience of ‘recovery’ for six male patients who were detained in a low secure service. Interpretive phenomenological analysis (IPA) was used to capture the subjective meanings that participants ascribed to this process. Participants also discussed the My Shared Pathway initiative as a helpful format for embedding recovery principles. Five superordinate themes were identified: It’s a journey; We’re vulnerable in here; Relationships with staff; Loss; and Hope. These findings are consistent with those seen in the forensic recovery literature and suggest that My Shared Pathway helps promote recovery in a number of ways. Clinical implications and suggestions for further research are given.

Realising transition pathways for a more electric, low-carbon energy system in the United Kingdom: Challenges, insights and opportunities

The United Kingdom has placed itself on a transition towards a low-carbon economy and society, through the imposition of a legally-binding goal aimed at reducing its ‘greenhouse gas’ emissions by 80% by 2050 against a 1990 baseline. A set of three low-carbon, socio-technical transition pathways were developed and analysed via an innovative collaboration between engineers, social scientists and policy analysts. The pathways focus on the power sector, including the potential for increasing use of low-carbon electricity for heating and transport, within the context of critical European Union developments and policies. Their development started from narrative storylines regarding different governance framings, drawing on interviews and workshops with stakeholders and analysis of historical analogies. The quantified UK pathways were named Market Rules, Central Co-ordination and Thousand Flowers; each reflecting a dominant logic of governance arrangements. The aim of the present contribution was to use these pathways to explore what is needed to realise a transition that successfully addresses the so-called energy policy ‘ trilemma,’ i.e. the simultaneous delivery of low carbon, secure and affordable energy services. Analytical tools were developed and applied to assess the technical feasibility, social acceptability, and environmental and economic impacts of the pathways. Technological and behavioural developments were examined, alongside appropriate governance structures and regulations for these low-carbon transition pathways, as well as the roles of key energy system ‘actors’ (both large and small). An assessment of the part that could possibly be played by future demand side response was also undertaken in order to understand the factors that drive energy demand and energy-using behaviour, and reflecting growing interest in demand side response for balancing a system with high proportions of renewable generation. A set of interacting and complementary engineering and techno-economic models or tools were then employed to analyse electricity network infrastructure investment and operational decisions to assist market design and option evaluation. This provided a basis for integrating the analysis within a whole systems framework of electricity system development, together with the evaluation of future economic benefits, costs and uncertainties. Finally, the energy and environmental performance of the different energy mixes were appraised on a ‘life-cycle’ basis to determine the greenhouse gas emissions and other ecological or health burdens associated with each of the three transition pathways. Here, the challenges, insights and opportunities that have been identified over the transition towards a low-carbon future in the United Kingdom are described with the purpose of providing a valuable evidence base for developers, policy makers and other stakeholders.

A comparison of the emotional and behavioural problems of intellectual disability offenders in medium and low security

Purpose There are few reliable psychometric measures of the psychopathology of offenders with intellectual disabilities (ID). However, previous research has indicated that the emotional problems scale (EPS) is useful in identifying a range of treatment needs and in predicting risk to self and others. The purpose of this paper is to compare the severity of the emotional and behavioural problems of a small sample of offenders with ID in medium and low secure services, as assessed by EPS. Additionally, the data are tentatively compared with those reported in previous research to precipitate discussion regarding the changes in clinical populations in secure care over time. Design/methodology/approach The study collected demographic and EPS data for patients with ID (n=25) on medium secure and a low secure wards. Data were collected as part of routine clinical practice, with EPS forms being completed by nursing and other multi-disciplinary staff. Findings It was found that there was no statistically significant difference in EPS scores between medium and low secure patients with ID. The authors also highlight differences between the current sample and the normative data collected by previous research. Originality/value The data regarding the psychopathology of medium and low secure patients with ID provide insight into the ever changing resourcing needs and risk profiles of this complex patient group. In addition, there is a dearth of empirical research that comments on the clinical differences observed over time in forensic populations. As the current data differ from pre-existing normative data, the potential shift in populations and also implications for the accuracy of clinical decision making based on the assessment are discussed.

Quality of low secure services in the UK: development and use of the Quality of Environment In Low Secure Services (QELS) checklist

Low secure services provide care for psychiatric patients whose risk cannot be safely managed in other settings. The physical environment in these units plays an important role in supporting recovery and risk management. We developed the Quality of Environment in Low secure Services (QELS) checklist to assess the quality of the physical environment of these services. Using recommendations from previously published standards we piloted a draft checklist with a weighted scoring system reflecting the views of patients and providers. The checklist showed good criterion validity and inter-rater reliability. Data collected from 33 low secure services showed considerable variation in the quality of the physical environment. The QELS checklist provides an accessible and reliable means for managers and clinicians to assess whether the quality of the physical environment of low secure units meets recommended standards and can be used to support efforts to improve the quality of care delivered by these services.

'Locked rehabilitation': a need for clarification.

Recently, the term ‘locked rehabilitation’ has spread from commissioning to now also clinical parlance. This is without any clear service description or category of patient which this service manages. Differences between this new term and an established definition of low secure services are examined and reasons for the introduction of this terminology are discussed. This is contextualised within service development, payment by results and measures of quality. It is argued that there is a need for ongoing measurements of types of patients admitted to, and treatments offered by, this ‘new’ ward, as well as those within psychiatric intensive and low secure care services.

An audit of the quality of HCR-20 violence risk assessments in a low secure service

AbstractIntroductionThe HCR-20 is one of the most popular structured clinical judgement tools used in forensic settings; yet, there are no published tools to assess the quality of its use. This study used the CAI-V, a tool to assess the competency of those carrying out risk assessment, to develop a quality tool for the use of HCR-20.MethodThe audit was carried out between July 2012 and July 2013 on all patients resident in St Andrew’s Essex, a low secure unit. The results of the first audit led to an action plan for clinical improvement, subsequently re-audited a year later.ResultsMost of the HCR-20 ratings scored in the competent range in both audits, but the greatest weakness was identified in the treatment planning section. The re-audit showed improvement, but there remained areas for development.DiscussionThe audit highlighted broad areas of improvement like the need for full multidisciplinary involvement, more attention to formulation, and the need for greater consultation and information gathering from outside professionals and family members. The quality tool developed could be adapted to the requirements of any service, and used accordingly.

Changing organisational culture: another role for self-advocacy?

Purpose – Improvements in organisational culture are a common recommendation of enquiries into system failure and an aspiration of policy. The purpose of this paper is to explore an initiative to change culture in a low-secure service through the introduction of a self-advocacy group. Design/methodology/approach – An independent evaluation was carried out by a university research team. A theory-based methodology was deployed with qualitative data gathered through observations, interviews and focus groups. Findings – Culture change was reported by senior managers and clinicians in relation to the transparency of the service, decision making regarding resources, and engagement of patients in redesign. Self-advocacy group members reported a different relationship with senior management which in turn enabled greater influence in the organisation. Achieving these impacts relied on independent and skilled external facilitation, support from senior managers, and a calm and democratic atmosphere in the meetings. Ward staff were kept at an arms-length from the group and were less certain that it had made any difference to the way in which the ward operated. Research limitations/implications – The research was only based in one organisation and the impacts of the initiative may vary with a different local context. Research in a wider sample of organisations and culture change initiatives will provide greater insights. Practical implications – Self-advocacy groups can lead to organisation culture change alongside benefits for individual group members but require funding, external and independent facilitation, and organisational endorsement and support. Originality/value – This paper adds to the limited literature regarding culture change in secure services and services for people with a learning disability in general and also to the understanding of the impact of self-advocacy groups.

Historical and clinical items of the HCR-20 as predictors of risk within an intellectual disability population

Purpose – The use of violence risk assessment measures within intellectual disabilities (ID) services is now the norm and a growing target for research. The purpose of this paper is to examine the clinical utility of the historical and clinical factors of the HCR-20 in predicting violence. Design/methodology/approach – The study took place within a national low secure service for adults with ID examining all completed admissions over a six-year period, (N=22). Clinical records covering the first three months of admission were examined along with historical reports and incident data recorded at three, six, nine and 12 months admission using the Modified Overt Aggression Scale (MOAS). Findings – Significant positive relationship between Historical score and total number of incidents was established. Patients with challenging behaviour less likely to have a previous history of violence, and more likely to be older at first violent incident than patients without challenging behaviour. Incidents involving patients with autism were less severe and those with no additional psychiatric diagnosis were significantly more likely to have substance misuse problems than those with a diagnosis. Originality/value – The study found the Historical section was predictive of violent incidents and whilst the study is too small to draw any firm conclusions, the significant positive relationship between the Historical Score and number of incidents for those without additional diagnosis needs to be investigated further as well as the potential positive clinical impact of using the HCR-20 in routine clinical practice.