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A year in the life of a new rehab hospital

A new male neuropsychiatric facility was launched in the UK last year, amid a national shortage of such services. Twelve months on, we visited Cygnet St William’s in Darlington to chart the ups and downs of getting the service going. As Andrew Mernin reports, it’s a tale of hard-won relationships, fire-fighting and people power.

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Good vibrations are bouncing around the communal room at Cygnet St William’s when NR Times arrives.

Partly, it’s down to the surprisingly large quantity of cakes on offer.

A local Headway representative is already tucking in, as is Paul, a friendly patient with a beaming smile.

Manager Alison King and consultant psychiatrist Dr Tony Perini are also in good spirits. But it’s perhaps not just the iced treats fuelling their positivity.

It could also stem from their satisfaction at the progress the facility has made after a year of hard work.

Cygnet St William’s is a 12-bed purpose-built facility for male neuropsychiatric patients in Darlington, North East England.

It has a UK-wide reach, helping to ease pressure on the UK’s neuro-rehab infrastructure.

As the acquired brain injury (ABI) all party parliamentary group report ‘Time for Change’ sets out, neuro-rehab beds across the board are in short supply – with 300,000 ABIs per year versus just 4,600 beds. More than three times that are needed to meet demand.

Despite working in the care sector since 1982, Alison says she’s learned a lot of lessons over the last year.

“One of them is that you can do all the planning you want for the important aspects, and have all the expertise on board, and then a fire that means you have to evacuate can put a spanner in the works. There are so many things you can never account for when you’re setting up a new service and you just have to overcome them as they arise.”

The fire, from an adjacent property, came just a few weeks after its first residents were welcomed. Thankfully no harm and little damage was done.

The hospital takes referrals of men affected by brain injuries and neurological conditions where challenging behaviour is the leading impairment.

They may have been detained under the Mental Health Act and have a forensic history.

Presenting comorbidities could include psychiatric disorders including psychoses, complex epilepsy, post-ictal psychosis and organic personality disorder.

For Tony, a standout challenge has been in establishing credentials to build vital relationships with CCGs.

“It’s not easy but if you’ve got the right ethos and the right sort of attitude and you’re doing what you say you’re doing, then you can gradually become a provider of choice.

“You’ve got to prove yourself as a new service, and initially may be tested on the most complex cases that others have declined to take on. It’s about making sure CCGs understand exactly what we do.”

The service is part of Cygnet Health Care, one of the UK’s largest independent providers of inpatient and residential mental health care.

Having assembled a well experienced interdisciplinary team, a crucial achievement has been the forming of relationships with GPs.

Alison says: “Getting the GP service on board was difficult initially.

“Our patients weren’t registered with GPs and so we had to work with the CCG to show the benefits of our patients being with a local GP, albeit on a temporary basis, and that took us a long time to get it worked out.

“We had to give them an understanding of what we are about and what we will provide.

“We arrange a lot of the appropriate medications ourselves, so we don’t require them from the GPs, but anything we do need, they’ll prescribe it and we’ll buy it ourselves.”

Tony says: “We all want to do the best for our patients and get the best out of the system and resources available to us that we can, so we are all working from a common place.

“We now have a good relationship with our local NHS colleagues and we’ve had dealings with the local hospital quite a bit.

“Establishing a relationship with primary care is very important because we are taking on individuals who potentially could have a quite rapid deterioration.

“Some are into their 80s and may get physical illnesses, which GPs are much better at diagnosing than psychiatrists with a few years away from general medicine.

“Without GP input, the risk is that you might either under react and miss things, or over react and over treat. So we are very pleased to have primary care there to advise us.”

Being transparent and accepting of scrutiny has been integral in forming vital links with other members of the healthcare ecosystem, meanwhile.

Alison says: “It helps that we invite external professionals in to have a look around and see what we’re doing here and how well it’s working.”

Tony adds: “A big part of us proving our credentials has been our policy of being open and honest. If we haven’t done something, or if something could have been done better, we will say so, and say ‘we’ve already identified this and it’s something we are going to address’.

“As an independent facility, you are under close scrutiny from the Care Quality Commission, but we are rightly also scrutinised by care managers and case managers because these are very complex cases we are working on.

“So we have regular meetings with them, and very clear targets from them which we have to deliver. “Contracting based on outcomes is good for them and for us in setting out what is realistic and what is ideal.”

On staffing, Alison says: “We discovered with the patients we had at first that individual’s needs were higher than expected. For example, we had more cases with physical complexities than we had factored into our planning. So we had to adapt to that by adding extra support and nursing staff.”

With new patients now being referred on an ongoing basis, to add to some of the unit’s longer-term residents – the longest duration for a resident to date has been eight months – the centre continues to grow its reputation.

Onsite, Alison has worked hard to establish a close-knit team with no bureaucracy and everyone encouraged to voice concerns. This approach, says Tony, enables them to deliver the best service to patients.

“We have genuine respect for each other here and we all want to strive to do the best for our patients. If this comes from the top downwards, it creates a good place to be. We want to be the best we can be – and I think Alison has managed to build the foundations for that in a very short period of time.

“Also, in the wider Cygnet group, the training is very good. Some is e-learning and some face to face, often at quite a large cost to the company. But it’s something we are all benefitting from. We want to retain staff and support them in their development.”

As part of the facility’s ongoing progress, plans are underway to better support patients approaching discharge back into the community.

Alison says: “We are just acquiring the building at present, but the plan is to create a three-bedroom transitional unit where individuals go from being in the existing centre.

“As they move towards leaving us, it will be a stepping stone for them to live more independently, living with support workers. It will be close to the existing building and we hope to get work underway this year.”

Further developments include the addition of a wider range of therapies, with music therapy and visits from animals among several new interventions
being introduced.

Alison is particularly excited about the animals.

“I saw the impact they could have when I used to work with elderly patients,” she says.

“We managed to find a local farm which can bring ponies in and they can visit the bedrooms – even going up in our lift up to the rooms on the first floor.

“Some of the patients we have here have lived around animals for a lot of their lives and it’s hard when you aren’t around animals anymore. Seeing animals can help to bring a bit of normality back. They have a very calming impact, and people’s eyes light up when they see them.”

Tony adds: “We’re always looking at things which will benefit our patients and have worked hard on creating the right setting. It’s is a great foundation from which we can build further.”

For more on Cygnet St William’s visit: www.cygnethealth.co.uk.

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Insight

Taking time to look back – so the way ahead is clearer

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Reflective practice within healthcare settings is widely talked about, but not always so easy to implement in the workplace. NR Times speaks to one neurological centre about how it benefits patients and staff there.

Reflective practice and discussion in healthcare settings is a professional requirement for nurses, as laid out by the Royal College of Nursing revalidation requirements as part of their continuous professional development.

It allows professionals to take time to pause and reflect, communicate and plan, which undoubtedly leads to better outcomes for patients and staff.

But in reality, reflective practice can often be left to the bottom of the pile, underneath many of the competing responsibilities facing staff who are often pressed for time.

It could be argued that this is also why reflective practice is so important – healthcare staff are facing so many pressures that it actually makes less sense to neglect the important work of individual and team reflection.

The Royal College of Nursing defines reflective practice as: A conscious effort to think about an activity or incident that allows us to consider what was positive or challenging and if appropriate
plan how it might be enhanced, improved or done differently in the future.

Staff at Elysium St Neots Neurological Centre in Cambridgeshire started doing regular, weekly reflective practices when its new hospital director, Fiona Box, came into the role a few months ago.

The nurses and healthcare assistants from a ward are invited into the meetings and in their absence the therapy staff monitor patients and provide activities.

“We thought it would be helpful for team members to give them the opportunity to think, learn, and to hear their opinions,” says charge nurse Jemima Vincent.

“If we have an incident with a patient, we discuss it in the session” she says.

Sessions are led by the management team, with added input from psychology teams on each ward.

They will talk through any strengths, weaknesses and opportunities, and work through an analysis to learn from the incident and create an action plan.

They talk about the worst-case scenario in relation to an individual situation and discuss how staff would manage that, so they’re better prepared in the event of it happening.

While they focus on one patient at a time, issues arise during conversations that bring in their wider experiences.

In an article* published in the Nursing Times in 2019, Andrea Sutcliffe, chief executive of the Nursing and Midwifery Council said: “In these challenging times for health and social care, it’s so important that collectively we do all we can to support our health and care professionals, and their employers, in devoting time to individual, reflective, personal and honest thinking.”

Fiona has received encouraging feedback from staff, who say the meetings help the staff feel much more involved in a patient’s care and allow the team to increase their knowledge and understanding resulting in a more consistent way of working.

“Healthcare workers often don’t fully understand patients’ diagnoses or why they’re reacting in a certain way, for example,” Jemima says.

“They know a patient presents with certain behaviours and may be taking medicine to help them cope but they’re not aware why the patient is showing signs of aggression and the best response to deescalate the situation,” she says.

“It’s a learning opportunity for staff, because reflective practice means that they can understand a patient’s diagnosis and why they behave how they do,” Jemima says.

“Reflective practice answers their ‘why’ questions, and gives them a more open mind.”

Jemima also benefits from the meetings; it’s a way for her to get to know staff better, especially when it comes to learning opportunities.

“I’m able to understand what level of support each member of the team requires, including training needs and if they need more knowledge on a specific topic.”

In her final year as a mental health nurse student on extended clinical placement at Elysium St. Neots, Jo took part in a reflective practice session.

She had just finished her dissertation, in which she looked at how settings can increase the opportunities and variety of reflective practices within hospital settings.

The aim of Jo’s session was to reflect on the recent deterioration in a patient’s mental state and the resulting impact on their well-being to ensure staff had a consistent approach to support the patient.

The hospital’s director Fiona asked the team about the patient’s care plan, diagnoses and needs and wishes.

Where staff were unsure of the answers to questions, Jo says Fiona gave them answers and encouraged the team to share their knowledge of the patient, problem solve and come up with an agreed plan to move forward with.

Jo found the session helpful and was impressed with how the healthcare assistants were so involved in the discussions about all aspects of the patient’s care, including the more clinical elements.

Healthcare assistants told her they found the session helpful too and that it made them feel like they had a better understanding of the patient’s changing mental state, behaviours and needs.

Jo says having the opportunity to reflect on practice is a crucial skill for all healthcare workers to help them learn from their experiences and increase self-awareness, which, in turn, can improve individual professional standards, strengthen teams and enhance patient-centred care and clinical outcomes.

For referrals to Elysium St Neots Neurological Centre or other Elysium centres visit: www.elysiumhealthcare.co.uk/neurological

Reference source: https://www.nursingtimes.net/news/ professional-regulation/nmc-highlights-importance-of-nurses- reflection-on-practice-18-06-2019/

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Robots and resilience at Askham Rehab

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NR Times reports on a new rehabilitation approach taking place in Cambridgeshire.

Despite a year of relentless change and upheaval for all involved in neuro-rehab, one provider in Cambridgeshire has been able to keep its ongoing development on track.

Askham Rehab, part of the Askham Village Community, is a recently-launched specialist rehabilitation service incorporating the latest in rehab robotics and sensor assisted technology.

While the firm has invested in state-of-the-art technology to do the heavy lifting, however, its rehab services remain person-centred, as director Aliyyah-Begum Nasser explains.

“We’re a specialist rehab centre in essence, and so, although the robotic technology helps us to get the most out of our patients and staff, we are very much family-focused.

The equipment is obviously fantastic but we know from experience that a person’s mindset, and their ability to sustain whatever improvements they make, comes down to the people who are supporting them – their family members.

“We’ve been on some real journeys with many of our family members who just didn’t understand the impact of a brain injury in terms of how it can impact behaviour or what it can do for cognition.

“Once they understand that, suddenly they become a lot more compassionate, and a lot more supportive; they become part of the recovery process, rather than being a frustrated observer.”

With recognition of the family’s paramount importance to recovery, Askham Rehab does everything within its power to harness this force – including by enabling families to stay together in specially-designed apartments on site.

Aliyyah-Begum says: “The flats are fully adapted, with cantilever cupboards, height-adjustable sinks in the bathroom and full wet room with turning spaces.

“We have the patients themselves participating in rehab, specifically to their programme, but relatives are also there from the beginning, seeing the improvement and being part of our process from the outset.

“We think of the centre as more of a rehab environment; it’s not a just care home with therapy as an added extra.

“So from the minute our patients wake up to the minute they go to bed, everything is based around their recovery goals, and everyone is working together towards achieving them.”

And robotics are an important tool in pursuing these goals through patient exercise. They help therapists to achieve the repetitions and intensity needed to progress their clients, as Aliyyah-Begum explains.

“The point of the robotics is that they respond to the patient. For example, if you set the machine on a left lower limb, but it senses that there is more pressure being exerted through the right limb than the left, it will automatically respond to make sure the patient is moving the correct part of their body.”

The centre’s head of rehab and nursing, Priscilla Masvipurwa, says: “This is a real a game changer in our approach to rehabilitation.

“Robotics help to bridge the gap, increasing the frequency and repetitiveness of treatment, something that’s an essential part of the process.

“We anticipate that this will enable us to support our patients in reaching their goals in a more efficient and sustainable way.

“The centre has so far invested in four items from robotic rehabilitation firm Tyromotion, but is looking to add more over time, as the benefit to both staff and patients becomes ever more evident.

Aliyyah-Begum says: “It’s really important to the team at the centre that the robotics aren’t just seen as an add on.

“There is a lot of nervousness about robots replacing therapists, but our service is still very much therapy-led.

“What this means in practice is that, where a resident would previously have had maybe an hour of therapy time in an afternoon, now you have an hour of therapy time, and then you can carry on exercising if you want to, or carry on playing games with other residents.

“For example, one of our machines, the Myro, enables patients to play games like bat and ball, or perform virtual tasks like sweeping leaves.

“However, because it is all sensor-assisted, if it senses that the patient needs to work a certain hand, it will alter what it is asking them to do accordingly, while they won’t even necessarily feel they’re having therapy – it’s all part of the game, and part of their socialising with other residents.”

Askham Rehab forms part of the Askham Village Community, on the edge of Doddington village, in Cambridgeshire.

It provides specialist care for people of all ages, offering day visits, respite care and continuing long-term support, both on-site or at home.

The site consists of five homes, three of which are specialist neurological facilities. In total, the neuro-rehab team can look after up to 52 patients at any one time, with 120 staff made up of rehab professionals and specialists.

The team comprises carers nurses, physiotherapists, occupational therapists, speech and language therapists and psychologists.

Aliyyah- Begum believes that the introduction of the robotic rehab services, combined with the patient-led therapy the group has been offering for 30 years, can only enhance the centre’s outcomes.

She adds: “We know that there is an increasing number of care homes that offer specialist therapy, but the difference with Askham Rehab is that we have embedded it into the whole culture of our setting – and the outcomes really speak for themselves.

“We often discharge people earlier than planned, and that’s a testament to the fact that the patients are really working hard with the team throughout their stay with us to achieve their goals – and that is the key.”

For more information about Askham Rehab, visit www.askhamrehab.com

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Astrocytes identified as master ‘conductors’ of the brain

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In the orchestra of the brain, the firing of each neuron is controlled by two notes – excitatory and inhibitory – that come from two distinct forms of a cellular structure called synapses.

Synapses are essentially the connections between neurons, transmitting information from one cell to the other. The synaptic harmonies come together to create the most exquisite music–at least most of the time.

When the music becomes discordant and a person is diagnosed with a brain disease, scientists typically look to the synapses between neurons to determine what went wrong. But a new study from Duke University neuroscientists suggests that it would be more useful to look at the white-gloved conductor of the orchestra – the astrocyte.

Astrocytes are star-shaped cells that form the glue-like framework of the brain. They are one kind of cell called glia, which is Greek for “glue.” Previously found to be involved in controlling excitatory synapses, a team of Duke scientists also found that astrocytes are involved in regulating inhibitory synapses by binding to neurons through an adhesion molecule called NrCAM. The astrocytes reach out thin, fine tentacles to the inhibitory synapse, and when they touch, the adhesion is formed by NrCAM. Their findings were published in Nature on November 11.

“We really discovered that the astrocytes are the conductors that orchestrate the notes that make up the music of the brain,” said Scott Soderling, PhD, chair of the Department of Cell Biology in the School of Medicine and senior author on the paper.

Excitatory synapses — the brain’s accelerator — and inhibitory synapses — the brain’s brakes — were previously thought to be the most important instruments in the brain. Too much excitation can lead to epilepsy, too much inhibition can lead to schizophrenia, and an imbalance either way can lead to autism.

However, this study shows that astrocytes are running the show in overall brain function, and could be important targets for brain therapies, said co-senior author Cagla Eroglu, PhD, associate professor of cell biology and neurobiology in the School of Medicine. Eroglu is a world expert in astrocytes and her lab discovered how astrocytes send their tentacles and connect to synapses in 2017.

“A lot of the time, studies that investigate molecular aspects of brain development and disease study gene function or molecular function in neurons, or they only consider neurons to be the primary cells that are affected,” said Eroglu. “However, here we were able to show that by simply changing the interaction between astrocytes and neurons — specifically by manipulating the astrocytes — we were able to dramatically alter the wiring of the neurons as well.”

Soderling and Eroglu collaborate often scientifically, and they hashed out the plan for the project over coffee and pastries. The plan was to apply a proteomic method developed in Soderling’s lab that was further developed by his postdoctoral associate Tetsuya Takano, who is the paper’s lead author.

Takano designed a new method that allowed scientists to use a virus to insert an enzyme into the brain of a mouse that labeled the proteins connecting astrocytes and neurons. Once tagged with this label, the scientists could pluck the tagged proteins from the brain tissue and use Duke’s mass spectrometry facility to identify the adhesion molecule NrCAM.

Then, Takano teamed up with Katie Baldwin, a postdoctoral associate in Eroglu’s lab, to run assays to determine how the adhesion molecule NrCAM plays a role in the connection between astrocyte and inhibitory synapses. Together the labs discovered NrCAM was a missing link that controlled how astrocytes influence inhibitory synapses, demonstrating they influence all of the ‘notes’ of the brain.

“We were very lucky that we had really cooperative team members,” said Eroglu. “They worked very hard and they were open to crazy ideas. I would call this a crazy idea.”

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