Independent Forensic Mental Health Review: interim report

6 Social and Environmental Conditions

Experiences of the hospital environment were a particularly important theme for people with lived experience of the forensic mental health system, who can spend long periods of time living in wards. Opportunities for activities and outings are important for people in hospital as a means of alleviating boredom, developing their skills and fulfilling progression requirements. Access to placements is uneven, which can delay people's progress.

Ward infrastructure and policies affect the degree to which people can retain a sense of privacy and personal space and maintain their personal relationships. Facilities for visitors vary and are inadequate in some units. People's control over their environment, including access to their bedrooms and retention of their belongings, influences their experiences of comfort and safety in a ward environment. A number of concerns were raised about ward safety. Weaknesses in this area are linked to poor staff retention.

Restrictions in forensic services are rightly higher than elsewhere in the mental health system but they vary in degree, even between different units of the same security level. Restrictive practices highlight the tension between measures to ensure everyone's safety and attempts to maximise people's freedom. People find some restrictions dehumanising and unhelpful for their recovery.

6.1 Activities and community placements

Opportunities for activities and outings are highly valued. People described activities on the ward as essential to alleviate boredom, to give a sense of purpose and achievement and to develop skills. Many people with lived experience commented on the difficulties of boredom and frustration when faced with long periods of time without structured activity, particularly on evenings and weekends. Gaps in services' ability to provide a range of activities that appeal to everyone are associated with dissatisfaction and demotivation.

Access to activities and regular routines outside of the ward is integral to a person's progression through the secure estate to the community. However, people with lived experience reported activities and escorted leave off ward being cancelled as a result of staff shortages.

6.1.1 Activities on the ward

In terms of ward activities, people with lived experience were particularly positive about opportunities to prepare meals as a means of giving meaning and structure to their days. Some wards provide people with a budget to plan and prepare the week's meals for staff and others people on the ward. This was seen as an example of good practice which enabled them to learn or maintain a number of skills. At the other end of the scale, one person in a low secure ward felt he was treated like a 'wee boy' as people were not even allowed to make their own cups of tea.

Several services discussed attempts to provide educational opportunities for people receiving care. They highlighted that while high and low secure services have access to core funding for adult education, medium secure services do not. Positive partnerships with local colleges have been made in some areas to provide education on wards. But there are also instances of these opportunities being withdrawn due to lack of interest.

Staff and people with lived experience commented on the importance of exercise. One person receiving care felt that people should be encouraged to do more physical activity. It was felt to be good practice for hospitals to make access to gym facilities easy. People who had gym facilities on their wards liked them. This was because they did not need a leave pass to use them.

6.1.2 Community placements and disclosures

People require access to meaningful and structured community placements or vocational opportunities in order to meet criteria for a discharge referral. These are used to promote skill development, social inclusion, employability prospects and structured routine within supportive and trusted environments.

A number of staff spoke of an increasing shortage of community projects capable of accommodating placements for people in the forensic system. This limits people's rehabilitation and opportunities for progression. One service said there should be a review of the interface with and capacity of community placements and the resources available to forensic services.

Disclosure of an individual's personal information must be carefully managed when on community placements in order to minimise risk whilst retaining privacy and discretion. Although there are organisations who have developed expertise in these matters, some third sector organisations expressed a need for more support to navigate them. Occupational therapy staff have developed some guidance on disclosure and are working with the Scottish Government to publish it.

Reports from advocacy confirm that people want paid employment to provide the dignity of some financial freedom alongside meaningful activity. People spoke of barriers to this. One person in the community explained that a clinical recommendation to his potential employer that he be supervised in the early months of employment meant the job offer was withdrawn. Other people had concerns about finding work due to stigma and fear of being worse off in employment than on social security benefits.

6.2 Privacy and personal space

6.2.1 Personal relationships

Inconsistent approaches to privacy affect people's ability to maintain relationships with their friends and family when they are in hospital.

On some wards, people complained that phones are poorly situated and do not allow for private conversations. For example, people in one ward said that the only phone they could use was located at the staff base. One person described a member of staff listening into conversations. An example of preferable practice was access to a portable ward phone which could be used in side rooms to ensure complete privacy.

Several family members commented on a lack of suitable facilities for visitors on wards. One explained that their visits had to be done with the door open at all times and two members of staff outside. Another said that a staff member stood so close during their visit that they felt they needed to include them in the conversation. This lack of privacy inhibited communication between people and their loved ones.

One person commented that wards do not seem to have any provisions for them to engage in intimate relationships whilst in hospital and that little support was given to prepare people for healthy relationships on discharge.

6.2.2 Bedrooms

People's access to their bedrooms is variable across the forensic estate and the variation is not explained by security levels. In some wards, people cannot access their room for long periods of time during the day. Staff said that this discourages isolation and encourages participation in ward activities. On others wards, bedrooms are kept open, people retain possession of their own key and are encouraged and supported to spend time in communal areas. Privacy in bedrooms in also variable. Some wards have peep screens that the people in care cannot close, others have no en-suite facilities and a small number of people do not have their own room.

Reflecting the length of time that they may spend in hospital, people expressed a desire for more 'homely' furniture and welcomed opportunities to personalise their space. In one low secure setting, people had complained about how uncomfortable the mattresses were but staff had simply told them they were standard 'forensic mattresses'.

6.2.3 Belongings

People talked about the importance of retaining their belongings during their journey through the forensic system and the distress they can experience when the system breaks down.

Several people relayed experiences of losing all of their belongings because they lost their accommodation in the community when they were admitted to hospital. This loss has both a sentimental and financial impact. People expressed frustration around a lack of clarity about where their belongings are meant go when they are admitted to hospital and who is responsible for this. Other people described spending significant sums of money to keep their possessions in storage. People also spoke of their belongings being lost when they moved within the secure estate. There can be significant delays in recovering belongings after a move.

It is important to people that they have some choice about the belongings they can keep on wards, given the extended period of many stays. The restrictions about the number and types of personal items that people are allowed varies. People receiving care felt these restrictions were not decided based on their needs. They felt decisions were made arbitrarily or depended on the staff's ability to keep track of belongings or available space on the ward.

6.3 Access to technology

Staff and people in the forensic system recognise that technology is a growing part of everyday life. Access to it is important for therapeutic, educational and financial purposes.

Access to technology and communication devices is restricted in forensic inpatient settings but the extent of these restrictions varies. People find this frustrating. Some policies do not allow people to access technology or only let them use basic mobile phones whilst supervised. Other policies permit use of smart phones. People want mobile phones or technology such as Skype to keep in touch with their support networks, especially if they are placed out of area. Staff reported that variations in access to technology across wards led to difficulties managing people's expectations at times of transition.

People with access to mobile phones and the internet said this was helpful. One ward was using this technology to help family members to join ward rounds. People on wards with more restrictive practices found the experience of digital inequality very difficult. The experience of moving between units to different levels of restriction caused frustration and anxiety. Lack of practice using technology left some people feeling unprepared and fearful of making mistakes in the future. Some AHP staff advocated for monitored access to technology to help people to carry out therapeutic work between sessions.

Some forensic services said that they are waiting for the Scottish Government to issue updated guidance on this. Some also suggested that the regulations on a specified persons' access to technology are severely outdated and require urgent review.

6.4 Ward safety and security

A small number of people receiving care spoke of feeling unsafe on their wards. They gave examples of being subjected to bullying, sexist, racist or homophobic behaviour from others. People felt that rather than addressing the issues with the bully, it was often the victim who was moved.

Issues around staffing levels were raised by a number of people. The relational security involved in forensic settings means that recruitment and retention of sufficient staff is a matter of safety for everyone in the ward. The review was told there are insufficient mental health nurses to meet the demand in forensic care. Staff spoke of being overworked due to staff shortages as a result of and resulting in long term absences due to stress and burnout. Difficulties with recruitment were associated with the perception that assaults are commonplace in forensic wards.

Staff shortages compromise ward safety. A small number of staff spoke about being physically and verbally abused on a daily basis. Some felt they were placed in dangerous situations and not provided with enough support. One person spoke of 'patients running the wards' and bullying by management. Some nursing assistants spoke of feeling undervalued by the system. In one area, they spoke of being left on the wards alone to manage people exhibiting extreme distress and being 'the ones getting bruises on our legs'.

A number of units operate as 'locked wards' because they do not meet low secure standards. The review witnessed smashed glass in wards, windows that could have items passed through and doors that were not robust enough. Staff recognise that these environments can be unsuitable for caring and treating people when their level of acuity rises. However, the difficulties in transferring people to higher security means they often have to be managed there where they are. This was felt to compromise the safety of staff and people receiving care on the ward. These concerns were exacerbated in wards that had no seclusion facilities.

Family members commented on different physical approaches to risk management between units operating at the same security level. One person, for example, was surprised at the airport style security at one medium secure unit having previously been to another where that level of security was not in place.

6.5 Seclusion and restraint

Use of restraint was a difficult issue for all respondents. It was observed that a culture of restraint for one person can change the ethos of a whole ward. Several family members reported instances where they felt that their relatives had been restrained inappropriately or excessively. People have found the experience 'terrifying'. However, there were also examples of restraint being used to prevent serious harm and many wards have started to use of 'Safety Pods' as a more trauma-informed practice than taking people to the floor.

There was widespread awareness of the Mental Welfare Commission's guide on the use of seclusion as alternative to physical restraint.^[11] Staff felt seclusion facilities allowed for better care and treatment for someone in hyper-distress and could potentially prevent the need to transfer them to higher security levels. On wards without specialist seclusion facilities, staff felt the management of people in their rooms was inappropriate and unsustainable.

Some staff reported difficulties managing people who became more acutely unwell and associated this with poor ward safety and injuries amongst colleagues. Concerns from people with lived experienced tended to be about the length of time seclusion could be used: stays of more than two weeks in seclusion were reported.

6.6 Other issues

Given the length of time people are spending in hospital, wards effectively become their homes. Issues that made things more difficult for people were the lack of consistent application of smoking policies between and within hospitals. Many people suggested that the smoking policies on forensic wards were more restrictive than on general wards. The heating on wards was also difficult to get right, with people on almost all the wards the review visited complaining it was either too hot or too cold and took too long to make changes.

Communal space was felt to be important in bringing connection and normality into people's lives. Staff highlighted a growing need for adequate spaces for therapeutic work given the greater emphasis on psychological therapies in current practice than when the forensic estate was originally designed.