Safe Spaces Scoping Report

7. Designing a Safe Space

It is recognised that individuals’ experience od distress, mental illness, and crisis fall within a spectrum, therefore in order to ensure a proportionate and appropriate response to crisis and distress it may be helpful to consider the notion of a tiered approach.

Safe spaces designed for responding to moderate to acute mental health crisis and distress would do well to be close to the ED and/or psychiatry ward in case of the need to escalate or transfer and would benefit from the availability of overnight accommodation. This type of alternative safe space would provide a suitable alternative to the legal place of safety where monitoring over several hours may be necessary. It may also be helpful for people who are at high risk of admission, but a period of monitoring would help determine what support is needed to allow them to be cared for in the community thereby negating the need for admission.

For individuals experiencing emotional distress with no requirement for clinical input, specifically staffed community spaces, with or without access to overnight accommodation, are of particular benefit to them. Peer support has been a common success factor in such community spaces, but this feature needn’t be exclusive to this tier of support. On the other hand, spaces such as community cafes, community centres or local community halls, could also offer support and advice for general wellbeing.

In community settings, should there be an escalation requiring a place of safety, hospital treatment, or urgent assessment, community pathways should be utilised, i.e. NHS 24 on 111, mental health unscheduled care services, conveying to ED, or contacting emergency services.

The Scots Review advised of barriers to accessing services and noted these can be easily overlooked. For individuals who have experienced trauma and poor treatment from public and/or health services, those with neurodevelopmental differences, individuals with sensory sensitivity, or for people in distress and crisis, a clinical environment can be triggering and overwhelming. Elements such as noise, lighting, and use of space can function as barriers to engagement and accepting help. Ensuring that safe spaces are designed to address and/or mitigate barriers to accessing care and support is crucial, with accessibility of safe spaces further explored at 7.4 and 7.5 below.

7.1. Place Standard Tool

It is known that identifying estates for safe spaces throughout Scotland could potentially be a challenge. Scoping may be required to identify if there are spaces throughout local communities which are unused during periods when unscheduled presentations are most prevalent.

When considering the implementation of safe spaces in Scotland use of the Place Standard Tool may be helpful in innovatively looking at spaces already available in communities which could be adapted to meet the needs of those in crisis and distress. The Place Standard Tool^[21] provides 14 questions/themes for discussion, prompting consideration of the elements which make up a place in a methodical way. The tool pinpoints the assets of a place as well as areas where a place could improve. It helps look at what is already available, the space, local knowledge, and patterns of behaviour, logically and methodically creating a space which promotes good health and wellbeing for all. The tool is designed to:

• Assess the quality of new and existing places to identify where improvements may be needed.
• Bring communities and the public, sector and third sectors together to deliver high quality places.
• Ensure people’s physical and social environments support good health and wellbeing.
• Promote consistency so everyone in Scotland has an equal chance of living in a good quality place.

7.2. Architecture and Design Scotland

Architecture and Design Scotland aim to inspire and support all those involved in designing and shaping our places. It focuses on fostering a culture of collaboration to improve the lives of people and to support inclusive and sustainable economic growth to create a more successful Scotland. It outlines the importance of future-proofing places to make them better for everyone. It describes the Place Principle as one based upon a shared understanding of what a place is for and what it wants to become, with partners and communities collaboratively agreeing the joint actions required to make that happen.

There are several tools and resources available on their website, including a case study sharing how Ayrshire and Arran created a therapeutic environment at Woodland View co-designed with the people using the service^[22].

7.3. Lived Experience

The Scottish Approach to Service design highlights that more responsive user-centred services can be designed by looking at the whole spectrum of needs created by life events and by understanding different pathways and emotional contexts. This not only improves the quality and efficiency of the services, but improves outcomes for people who are trying to access services during stressful periods of change. Providing targeted assistance at times of greatest need – and delivering the very best user experience - creates more positive and trusting interactions between citizen and state. Designing services in collaboration with partners and the people who will use them, including targeted and meaningful engagement with diverse lived experience and grassroots equalities organisations, will provide unique insights and the opportunity to deliver long term - positive change.

Core Mental Health standard 5.1 requires: I (the service user) will be asked about my experiences and this feedback will be used to improve services. With my agreement, my support network will also be able to offer feedback.

Involving local communities in the design of safe spaces also provides the opportunity to overcome stigma associated with mental health crisis and other associated issues, helping local citizens to feel safe and more likely to have an inclusive response to the safe space within their community. It may also help increase awareness of the service, including among potential employers and other services, who can signpost to the service.

7.3.1. Suicidal crisis

Consultation to inform the Time, Space, Compassion Three Simple Words, One Big Difference report, published in 2021, suggests that stigma and discrimination, a fear of being a burden, and a lack of compassion were identified as the top barriers to help-seeking. Respondents highlighted the importance of having sufficient time to talk about their feelings and of support being available at the time they need it, including out of hours. Respondents felt that access to confidential safe spaces where people would be seen quickly and privately would encourage people to seek help. They also expressed the view that people providing support at a time of crisis should be suitably trained to respond to suicidal ideation and should be equipped with the knowledge and ability to signpost to appropriate onward support.

Research conducted by Samaritans^[23] into their caller outcomes also supported this, with callers reporting reduced levels of distress following the calls and particularly valuing the 24/7 nature of service, the time to talk things through, someone really listening, offering confidentiality and anonymity, and a human connection.

It goes on to outline that physical spaces for people who seek support in suicidal crisis should be accessible, quiet, comfortable, pleasant, and take account of emotional and physiological needs. There are strong links with the work to raise awareness of the impacts of trauma, it is therefore critical that spaces where support for those in suicidal crisis are trauma informed. People should feel they have the space to explore the thoughts in their head and the reasons behind their suicidal crisis in the course of a confidential therapeutic conversation.

7.3.2. Children and Young People

The Suicide Prevention Youth Advisory Group[24] discussed physical space for support and highlighted the importance of services and support being available locally and in appropriate spaces. Often people felt like they did not have access to support in the spaces around them. Unsurprisingly, this is particularly pronounced in rural areas. Often young people who live in these areas describe having to travel long distances to get the support they need.

People also highlighted how the support that is available often is not appropriate. For example, some forms of support can be available in school, but it is not well developed. They also spoke about issues with drop-in services in spaces like libraries which can end up being stigmatising as it is in a public place. In addition, other members of the group highlighted how, when spaces are pitched in the right way and held in the right places, they are sometimes not felt to be available at the right time.

Members of the group identified that often they felt safer and more supported when accessing support through third sector organisations than through the NHS as they can work in a different way to the NHS. Feeling safe in a space made it easier for members of the group to share how they are feeling.

They also discussed the importance of spaces where people access support being fully accessible for people with different protected characteristics. This included being physically accessible for disabled people but also about feeling like welcoming, accessible spaces for young black people.

The group discussed the importance of trauma-informed spaces and space’s design reflecting this. They felt that everyone has a responsibility to be trauma-informed but this goes further than just practice and must feed into the spaces where services are delivered. Services should be designed with the needs of those accessing them in mind and consider how the whole environment impacts on them.

Less formal spaces that can support people’s health and wellbeing were also seen as important. Some members reported feeling relaxed when playing music or gaming online. This highlights the importance of non-therapeutic spaces for supporting people’s wellbeing, including the importance of involvement in activities like music and gaming.

The Hot Chocolate Trust supports young people in Dundee to take responsibility for their own lives and their impact on others so that they can live fuller and healthier lives. The charity was founded by members of The Steeple Church, who began talking to young people hanging out on the grass outside the church. Relationships were built over cups of hot chocolate and trust began to grow between the young people and youth workers. Over time many shared their experiences, including bullying, family breakdown, and mental health issues.

The founders asked, ‘If you had a wee bit of space within the building, what would you use it for?’ Young people were encouraged to develop and sustain their own activities. The variety of opportunities that resulted from youth work sessions and individual support to residential weekends and an intensive summer programme, matched the diversity of young people involved. There are number of resources available on the Hot Chocolate Trust website co-designed with young people using the service expressing what was is important to them about the service. Their 2022 Annual Report^[25] highlights the importance of:

• Viewing young people as a whole, supporting their holistic development which realises physical, mental, emotional, social, and spiritual potential.
• Building relationships based on respect and trust, relationships which are voluntary and two-way.
• Growing a community with young people which is safe, welcoming, and affirming to all.
• Ensuring that plans and activities are owned by young people, adapted with the culture, and bring positive change for all involved.
• Knowing what the service is good at, and not so good at: working with other people and organisations who can provide specialist opportunities for young people that the service couldn’t make happen on its own.

7.3.3. Mental Health Diverse Experiences Advisory Panel

The Diverse Experiences Advisory Panel (DEAP) considered a draft of this report, and they were supportive of the need for additional safe spaces and shared that it was important that safe spaces focused on both clinical and non-clinical supports and settings. The DEAP noted the focus of the report appeared quite clinical, adding that at times, safe spaces will be needed as a refuge when a person is feeling overwhelmed and may not want clinical input. The spaces will require careful design and implementation since it is difficult to predict how people will react, so safeguarding processes will be very important.

The DEAP noted that a person would sometimes require support, but other times simply having a safe space to be at would suffice. . They clarified that the space’s design is important so they are safe and quiet, and people are treated with respect. They added that individual rooms would make sense.

The DEAP thought that safe spaces must be open to all based on their needs at the time, without any criteria or entrance requirements set. The design should suit the needs of all people, e.g. older men, who are the group most at risk of suicide. They noted there will be a need to make sure those using a safe space are not triggered by other users, e.g. someone under the influence of alcohol or other substances.

The DEAP highlighted that the approach of staff will be very important; they must be welcoming, compassionate and empathetic and not show any bias. Staff training resources will also be very important, with staff being able to signpost to supports for particular issues.

Shame and stigma can be a barrier to accessing services for some. Will need to think carefully about the design of the entrance, signage, etc. Stigma, both internal and external, could be barriers to using safe spaces.

A major barrier in rural areas will be transport: car ownership is low and public transport poor. This will be less of an issue in cities. The cost of transport could also be a barrier for many, particularly those on low incomes, including refugees and asylum seekers. Caring responsibilities co be a barrier to accessing a safe space.

They highlighted that people in crisis can’t always express what they need fully. Initially some may require assistance to relax and calm, e.g. breathing exercises, meditation, etc.

Translation services will be required for those who do not have English. There is potential for cultural practitioners to be involved – music can be relaxing and arts can be a way of expressing needs and feelings. Spiritual care could be a part of a safe space – but it is important to note that faith organisations can also be the cause of a crisis

They also noted that issues around messaging and marketing will need careful consideration. How will we know where a safe space is and what it can provide? Links should be made to workplaces – employers can signpost to safe spaces if necessary.

7.3.4. Australia – What makes a space safe

Lesley et al published a paper on What makes a space Safe? (2023). This qualitative study asked people in Western Australia with experience of presentation at the emergency department during a mental health crisis to describe what a safe space would look and feel like. Data was collected through focus groups and thematically analysed. The findings present the voices of mental health consumers lived experience through the framework of health geography and the therapeutic landscape. These participants articulated important physical and social features of a therapeutic safe space and their symbolism as inclusive, accessible places where they would experience a sense of agency and belonging. Participants also expressed a need for trained peer support within the space to complement the skilled professional mental health team.

7.3.5. Hope Point Dundee

Hope Point a newly opened wellbeing centre in Dundee has demonstrated the value and importance of lived experience input in designing their new centre. The local Third Sector Interface, Dundee volunteer and voluntary action, were asked to ensure that the people living in Dundee had the opportunity to contribute and meaningfully express their views in the development of the centre. Themed sessions were held with 68 participants in attendance, as well as surveys for wide distribution and conversation cafés were also held. Information such as how should people access the centre, what should the experience of accessing the centre look and feel like and what should the building space or surroundings of the centre be like? From these engagement and information gathering sessions the development team were able to ascertain what the community needs were and design these into the service to ensure the centre meets the needs of those in Dundee.

7.3.6. The Neuk (Perth)

An independent evaluation ‘A Safe Place: The Neuk Mental Health Crisis Centre’ published in February 2023, demonstrated positive impacts from the perspective of service users, staff and partner organisations.

Service user interviews illustrated the often profound and meaningful impact that the Neuk has had on its service users. The report highlighted the non-medical, peer-led approach to support that the Neuk provides, within a homely setting that is open every day of the year as consistently important aspects of the service.

7.4. Equalities

Additional safe spaces should be accessible to everyone they are seeking to support. The core mental health standard 2.1 requires: ‘The help I [service user] receive will be centred around me, respectful of my choices and based on the evidence about what is most likely to help me. This will take into account my cultural and social needs, and will aim to follow the principles of trauma-informed practice’.

7.4.1. The Mental Health and Wellbeing Strategy Evidence

The review^[26] reflects on some of the key challenges impacting upon population mental health and wellbeing that the strategy needs to tackle, and in response to this, considers evidence-based approaches to addressing these challenges. While the entire evidence review will be relevant to the development of safe spaces the following are highlighted as essential to consider:

Access - the need for attention to be paid to meeting the different needs of individuals and groups, and for care and support to be effective, it needs to be accessible in the first place. It is necessary to consider new models of service provision, with a spectrum of levels of support, differing modes of access including a greater digital offering, and more provision within communities. We know, for example, stigma within some minority ethnic communities, older adults or people in the perinatal period can act as a barrier to accessing support and services. Geographical barriers and lack of targeted or inclusive communication can also adversely affect certain marginalised groups. These should be considered in the design of service.

Stigma - The Scottish Mental Illness Stigma Study emphasises that stigma and discrimination are prevalent in emergency services, particularly for those with severe and enduring complex mental illness. The report highlights that 58% of respondents have stopped themselves from attending emergency services calling an ambulance through perceived experiences of stigma. It also highlights experiences of discrimination from staff within mental healthcare settings with 87% stating they experienced unfair treatment when trying to get help for their mental health.

See Me have found that service users report poor experiences within emergency care, for example, stigmatising comments from nurse healthcare staff and early discharge without appropriate support. They report that when attending ED for mental health illness, staff can make them feel as if they are taking up space meant for people who really deserve it/don't have self-inflicted injuries/mental health crises. Some respondents highlighted that they would be more likely to seek emergency support knowing that safe spaces are in place - with an emphasis on ensuring that the service was stigma free and compassionate. They support the inclusion of peer support within services and the importance of training to take an anti-stigma approach, such as the Scottish Recovery Network’s CHIME framework.

Prevention - Greater recognition of the importance of creating the conditions to prevent reduced wellbeing or mental ill health developing or worsening in the first place is essential. Strong communities, peer support, and enhancing understanding of the nature of wellbeing and mental health and its influences across society, and particularly within the workforce beyond specialist mental health professionals, all support this. The causes of health inequalities arise from the unequal distribution of income, wealth and power, which can impact on wider life chances and experiences. These societal conditions put some groups at greater risk of poor mental health than others. These conditions are commonly known as ‘social determinants’ and include traumatic and adverse experiences such as poverty, discrimination and loneliness which can disproportionately effect certain marginalised groups.”

Severe and Multiple Disadvantage - People experiencing severe and multiple disadvantage may experience several overlapping problems at the same time. Estimates suggest that, over a year, there are 41,000 people experiencing poor mental health plus one other disadvantage from homelessness, substance dependency, offending or domestic violence/abuse. People with lived experience of such multiple disadvantage describe the struggle of local and national service systems to address the needs of people who present with a range of complex and interacting needs. This is especially so if these needs are accompanied by the perceived challenging forms of behaviour that are often present in people coping with the long-term effects of sustained trauma.

7.4.2. Core Mental Health Standards

While the intention is to initially apply the Core Mental Health Standards^[27] to Adult Secondary Services, Psychological Therapies and Interventions and services that treat those with an eating disorder, it is the ambition for them to be applied to all mental health services in time. They seek to address the inequalities in outcomes and experiences for people accessing mental health services. We know that access to and experience of mental health support and services is not experienced equally across the population. The Core standards set out a desire to apply an intersectional approach to effectively understand and tackle structural inequality, recognising people are multi-faceted and different experiences or aspects of their identity interact to affect their mental health. The application of these standards should ensure support, services, care and treatment that are anti-racist, culturally sensitive and inclusive.

7.4.3. Protected Characteristics

7.4.3.1. Age

The Out-of-hours pathway for children and young people is not currently uniform across Scotland with significant variation in how health boards respond to children in crisis, including age criteria. There are also fewer alternatives to ED or admission for children in the out of hours. The needs of children and young people feature significantly in need for alternatives safe space, it therefore likely they would benefit significantly. However, as described below, care is required to ensure that they are designed to meet their needs.

There is some evidence to suggest that young people may prefer face-to-face, text, or web-based support over telephone support. This may limit the entry point options that children and young people are comfortable using or consider safe.

Older adults are more likely to live alone, less likely to have internet access, and less likely to use the internet even if they have access to it - all factors that not only have an impact on their mental health and wellbeing, but on how they access information and support. Older adults, regardless of where they are residing, are at risk of being unaware of services if communication is not targeted at them or services already supporting them.

7.4.3.2. Disability

The design of safe spaces should actively consider barriers that often exclude disabled people. Disabled people, people with long term conditions and unpaid carers often experience inaccessible community services, green spaces, and town centres. Examples of lack of access to public, accessible toilets or changing places, poor public transport links and inaccessible buildings were highlighted. Ramps and hoists should be available within space to ensure equity of access.

Care should be taken to ensure people with learning disabilities are not negatively discriminated against through diagnostic overshadowing. Negative experiences may further result in frustration, mistrust, and cynicism. If appropriate and flexible support is not provided, they may retreat or withdraw, increasing the risk of a more significant mental health crisis. People with learning disabilities may also require various accessible communication formats. Any messaging on accessing safe spaces may indirectly discriminate against people with learning disabilities if it doesn’t account for this group’s lower use of internet and technology.

People with sensory loss experience higher levels of mental ill-health than the general population, so the design of safe spaces should consider people with sensory loss’ particular accessibility needs. Any communication and support material should account for the variety of accessible formats required, such as BSL, larger print text, Braille, or text-to-speech, otherwise there is a risk that the existing inequalities are exacerbated.

Adults and young children that are neurodivergent often face difficulties in processing their environment. Therefore, sensory exposure, (e.g. light sensitivity, noises, temperature and texture) should be considered. Further, a space that is difficult to navigate can create a stressful environment for neurodivergent people can add unnecessary barriers to accessing support. Designing spaces with engaging and intuitive navigation will help reduce such barriers.

7.4.3.3. LGBTI+ (Sexual orientation and gender)

There is significant evidence to indicate that LGBTI+ people in Scotland are at much higher risk of Mental Ill health, distress and crisis than heterosexual/cisgender people, with self-reported mental health concerns being highest among trans-masculine, non-binary and bi women populations.

In rural areas particularly, the lack of services, safe spaces and LGBTI+ groups create barriers to accessing mental health support. In the Further Out: Scottish LGBT Rural Equality report, respondents noted the comparative absence of services in rural regions compared to those in the central belt of Scotland, which included health services such as GPs and mental health services. It was recognised that these services were available for those willing to travel, but the need to travel furthered heightened feelings of isolation.

The MWC LGBT Inclusive Mental Health Services report^[28] highlighted the importance of create an environment where LGBT people feel safe and able to be themselves. Individuals should not need to hide who they are for fear of negative reactions or harassment. Services should provide LGBT training due to poor experiences of people e.g. misgendering in the past or not understanding cultural differences may lead to issues. Ensure LGBT friendly posters and leaflets are displayed and local LGBT groups are signposted. The LGBT Health and Wellbeing audit tool can help assess how LGBT friendly a service is, and inform an action plan to deal with any issues found.

7.4.3.4. Minority Ethnic Groups

The Mental Welfare Commission, Racial Inequality Scotland Report found that more people who were black or of mixed or multiple ethnicity were perceived as a greater risk to themselves and others, whereas all categories of white people were more often perceived as a risk to themselves. They are also disproportionately subject to detention when compared with detention amongst Scottish/white groups.

Trauma as the result of the immigration system can also be a factor that negatively impacts mental health, and exacerbates discrimination. Staff should be trained in trauma-informed practice and have an awareness of the asylum process.

Factors that might make alternative safe spaces are more inclusive to this group are reducing stigma associated with mental health, targeted awareness raising, removing language barriers, increased workforce diversity, as well as quality cultural competency and sensitivity and anti-racist training.

7.4.3.5. Pregnancy and Maternity

Where a pregnant person is seeking crisis support, there is a risk that their and the baby’s physical health is prioritised over their mental health. Evidence shows that parenting support programmes, peer support and counselling can all be beneficial for pregnant women and mothers.

7.4.3.6. Religion or Belief

There is evidence that discrimination towards religious minorities can have an impact on accessing services. There is a need for culturally aware support services for some religious groups, including outreach services, the ability to navigate language barriers and provide sensitive and appropriate support. Training to actively counter discrimination, including Islamophobia and its impacts, is noted as being an important provision for services.

7.4.3.7. Sex

Barriers for both women and men accessing services and support include mental health stigma. For women, the impacts of experiencing violence against women and girls can also act as a barrier. There is a higher prevalence of caring responsibilities among women, Hope Point noted the importance of informal childcare featuring in their centre, this will be of particular benefit to women who are known to hold more caring responsibilities.

7.5. Care and Safety Planning

The Scottish Recovery Network described “Recovery [as] being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms. It is about having control over and input into your own life. Everyone’s recovery, like his or her experience of the mental health problems or illness, is a unique and deeply personal process.” The process of care planning should enable people to take more control of their lives and ensure that the person’s perceived needs and aspirations have been considered. A good care plan will have the individual, not just their symptoms, at the heart of it.

To support and facilitate long-term care and in response to criticisms raised in the Ritchie Report, the Care Programme Approach (CPA) was introduced. This was to provide a framework for the delivery of effective mental health care. Its four main elements are:

• Systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services;
• The formation of a care plan which identifies the health and social care required from a variety of providers;
• The appointment of a key worker to keep in close touch with the service user and to monitor and co-ordinate care; and
• Regular review and, where necessary, agree changes to the care plan

The Scott Review also highlighted existing frameworks such as the Care Programme Approach could be helpful, particularly for people who may experience distress frequently. Implementation of CPA could be part of the proactive follow-up which the safe spaces could be involved in as part of the whole system, whole person approach.

The Core Mental Health Standards also set out requirements relating to care planning including:

• The help I receive will be centred around me, respectful of my choices and based on the evidence about what is most likely to help me.
• This will take into account my cultural and social needs, and will aim to follow the principles of trauma-informed practice.
• If I need help from multiple professionals and agencies, I will have a designated person who will offer support in coordinating these.
• Alongside consideration of my assessed needs, I will be asked what is important to me and this will inform my mental health and wellbeing assessment and the help I receive.
• I will have one written care and treatment plan which is jointly created by me and the professionals supporting me.
• I will have access to my care plan which will be regularly reviewed to ensure it continues to reflect my assessed needs and what is important to me.

7.5.1. Future Care Planning (previously anticipatory care planning)

The Mental Welfare Commission report on Person Centred Care Plans sets out that everyone using mental health services has the right to a care plan which is personal to them. They also have the right to be involved in developing their care plan, to know what is in their care plan, and to be involved in reviewing their care plan^[29].

It goes on to explain that care plan describes the care, treatment and interventions that a person should receive, to ensure that they get the right care at the right time. It is a written record of needs (either electronic or paper-based), actions and responsibilities, which can be used and understood by individuals receiving care, their relatives/carers and others as appropriate.

7.5.2. Patient Experience and Anticipatory Care Plan (NHS Lothian)

Lothian Health Board Patient Experience and Anticipatory Care Plan Team (PACT) also recognised the vital role of care planning implementing this for a relatively small group of patients who repeatedly presented to hospital either in acute crisis or due to one or more long term health condition. The team sought to improve the care provided by listening to the individual’s experience of care and working with them to develop an individualised, person-centred Anticipatory Care Plan (ACP) designed to support them in managing their own illness and to ensure more consistent management when they do present to hospital.

PACT used an algorithm to identify people frequently attending the Emergency Department (ED) and other patients at very high risk of acute hospital admission. Each patient was allocated to the most appropriate PACT key worker: an experienced ED charge nurse or consultant. Two independent evaluations found that PACT care plans achieved a measurable reduction in acute hospital demand, while also receiving overwhelmingly positive feedback from patients, and significant service savings of £7 for every £1 spent on the programme. Unfortunately, whilst the service significantly reduced acute hospital demand, in the absence of "cash release savings", NHS Lothian was unable to identify a funding stream.

7.5.3. Crisis Planning

The Good practice guide Person Centred Care Plans noted the limitations of care plans at the time of a crisis however, felt there was still a role for an admission care plan to cover initial identified needs, allowing time to undertake a more detailed assessment. An initial admission care plan may cover the first 72 hours of an admission and after this time it should be discontinued and a more detailed future care plan put in place.

For the purposes of safe spaces, consideration should be given to the initial development of a care plan, with the view to reviewing depending on the individual need and presence of risk. It would be key for all safe spaces whether providing support to low or high crisis and distress, to apply a consistent approach to this. Ensuring a collaborative and joint approach with partners, including third sector organisations, emergency responders and clinical health professionals with information sharing agreements in place to ensure proportionate and appropriate sharing of information. This in turn would aid and inform responses ensuring the right support is given at the right time.

7.5.4. Safety Planning

Supporting safety as a suicide prevention tool must be a key factor in providing support within alternative safe spaces. The Time, Space, Compassion principles require asking about and taking action that helps people feel physically and emotionally safe; using and staying up to date with national guidance and practice on safety planning; if needed, being able to get people to a safe place; being clear on confidentiality and when you would share information with others.

The NICSH toolkit for specialist mental health services and primary care recommends that patients discharged from psychiatric in-patient care should be followed-up by the service within 72 hours of discharge. A comprehensive care plan should be in place at the time of discharge and during pre-discharge leave.

It also recommends that all patients’ management plans should be based on the assessment of individual risk and not on the completion of a checklist. Patients should have the opportunity to discuss with their mental health team the signs that they will need additional support, such as specific stresses in their life (e.g. economic adversity, experience or threat of domestic violence), anniversaries and dates that are important to them and online experience. Families and carers should have as much involvement as possible in the assessment process, including the opportunity to express their views on potential risk. Consulting with the patient’s GP may also be helpful.

Risk assessment is one part of a whole system approach that should aim to strengthen the standards of care for everyone, ensuring that supervision, delegation and referral pathways are all managed safely.

7.6. Digital and Telephone support options

While this report explores the concept of additional physical safe spaces, including digital and telephone support within these spaces can add value by allowing individuals the opportunity to self-refer and/or access support from their device, anytime and anywhere that suits them. Many of the good practice examples outlined in the Annex also provide options allowing individuals to contact the service by telephone or through the use of Near Me. Early evidence from the Hope Point centre suggests that telephone contacts have increased as relationships and trust develops.

The Core Mental Health standard 2.11 requires: I will have a choice in how I prefer to access care and support and whether I engage digitally or face to face. However I access support, the environment will be safe, clean and will enable effective treatment.

7.7. Proactive follow-up

The David Strang Report (2020)^[30] discussed the importance of proactive follow-up and noted the variance in risk assessment across practitioners. The Inquiry found that staff reported services running on a lower than optimal staffing model. This meant the service did not have capacity to be responsive and operated only in a reactive manner. Risk assessments in crisis services focus on the risk of serious harm/death. It was noted that this may, at times, under-value a patient presenting in severe mental distress but with no imminent risk to life. If a risk assessment indicates no risk to life, the patient is treated as a non-urgent referral to other services. The report highlights that individuals who are judged to have a low-risk to life but are in high-distress, may have a very poor level of community follow-up. The result is often that the patient is repeatedly referred back to crisis provision as GPs and families struggle to manage the patient’s declining mental health condition, without adequate community support. These circumstances often also show an increased risk of self-harm as patients feel they have no other way of getting help.

The MWC’s review of Psychiatric Emergency Plans across Scotland outlined that all health boards were asked if there was guidance on how to manage patients when they present in crisis despite an assessment stating they do not need immediate treatment. The report noted two health boards addressed this area but 12 did not (this has likely moved on given the improvement work described above). The report noted that not all patients presenting in mental health crisis will require immediate treatment, but alternative pathways should be available and this could include proactive follow up from or referral to in-hours services.

This highlights the importance of proactive follow-up to avoid the escalation, or continuation, of mental health crisis and distress. This should feature for individuals who present at the safe space who are not in immediate risk, high distress, with the ability to share information appropriately with local partner agencies to ensure a joined up approach.

7.8. Protocols

The need to ensure appropriate and safe processes and protocols are in place is essential regardless of the tier of support being provided. Inclusion of the following protocols may be necessary depending on the level of crisis support being provided and the risk associated with it;

7.8.1. Safe Handover

Local partners need to have a shared policy outlining the process for referral, sharing information, assessing risk and safe hand over of the individual to the safe space, planned services, emergency services/clinical team and review processes etc.

7.8.2. Information sharing protocols

In addition to sharing information when transferring care, information sharing protocols with key partners should be in place to allow the sharing of critical information that supports continuity of care and safety. This should provide the ability to share information with health and emergency services and for the safe space to receive critical information from these services. This should include consideration of consent to share information where this is not legally required to support safety.

7.8.3. Consent

With the exception of section 297 of the Mental Health (Care and Treatment) Act (2003), which would require conveyance to a specialised assessment unit/safe space; all other support/admissions must be on a voluntary basis and all safe spaces will need to have a process in place for recording the individuals’ consent.

7.8.4. Deprivation of Liberty

Due to the above, the safe spaces will need to consider practices which are least restrictive such as no locked door and individuals having the freedom to leave when they desire.

7.8.5. Escalation processes

It is advisable to have a robust escalation process for clinical support and advice to ensure the best care is provided for each individual. In community settings, should there be an escalation requiring a place of safety, hospital treatment or urgent assessment, community pathways should be utilised, i.e. NHS 24 on 111, mental health unscheduled care services, conveying to ED or contacting emergency services. Every staff member should receive de-escalation training and have an awareness of their right to feeling safe at work.

7.8.6. Significant risk to safety

Implementation of personalised and contextualised management of risk will be essential, given that the safe space will have limited legal authority to restrain or restrict. The safe space will need to consider the process for occasions where an individual presents within the service or voluntarily leaves the service and there is significant risk to their safety or the safety of others.

7.8.7. History of violence

Consideration to the management of risk to others and staff will also be required should the service include support for individuals who have a prevalent history of violence.

7.8.8. Access to medication/prescribing

Clear policies and guidelines for accessing medication will be need to be in place particularly for safe spaces providing overnight accommodation. Woodland view, for example, will implement a policy of utilising medication from home.

7.8.9. Staffing Ratio

Clear policies and protocols should be established to ensure safe staffing levels are achieved to ensure high quality and effective care or support to the individual and to ensure that staff are also safe and protected. Safe spaces created in an health or care setting will be subject The Health and Care (Staffing) (Scotland) Act 2019 which came into force on 1 April 2024. The Act places a legal duty on NHS and care providers to make sure there are always suitably qualified staff working in the right numbers for safe and effective care. It also imposes a duty on the Scottish Government to ensure there are sufficient numbers of registered nurses, midwives and medical professionals available to enable employers to meet their duty to ensure safe staffing. When planning staffing around service it should ensure the relevant time required to safely seek support and allow the time for service users to discuss distress without a time limit.

7.8.10. Access to security

On occasions where an individual in acute mental health crisis and distress experiences an escalation in presentation which places staff and others safety at risk. Consideration to escalation routes to policing or on/site security if located within a hospital should be given. It is widely recognised that Police are not the most appropriate service for responding to mental health crisis and distress. However, Police Scotland and others, acknowledge a role for police when there is significant risk of harm to the individual or others. Stakeholders should work collaboratively in order to manage risk and ensuring the patient experience is as positive as possible.

7.8.11. Access routes to urgent physical health treatment

Health in general is not a static entity and individuals presentations can be changeable, requiring review, re-assessment and referral. In occasions where an individual who previously did not require medical intervention, now requires acute medical care, the safe space, when not co-located within acute settings, must have protocols in place to enable quick and efficient transfer of care.

7.9. Overburdened Service/Predicting Demand

Engagement with those who have established alternative safe spaces, or are in the process of doing so, suggests that there are often concerns that services, once established, will quickly become overwhelmed. However, this has not transpired when services have tested the service or when it became fully operational. This has been mitigated by designing services in collaboration with partners, having a clearly defined purpose which is widely communicated.

7.10. Geographical and demographic differences

There is significant variation in mental health unscheduled care demand across Scotland and while high population areas may be able to operate a 24/7 safe space, more rural and suburban areas may only require this on an ad hoc basis. This means that a safe space that requires a specialised staffing with a set staffing ratio and open during set periods may not be feasible within these locations.

For example, a fully operational 24/7 service, medium tier service could require 2 staff to be employed and available to support a person in crisis. In some rural areas they may only experience demand for the service once a week or once a fortnight. Even in medium population areas, it may be that there is reasonable demand for a service up to 22:00 in the evenings but rarely during the night. Service demand will also be dependent on what the operating hours of other crisis services available in localities.

A flexible approach will be required in order to meet the varying needs and demands of local areas across Scotland, which can realistically and practically moulded to each Health Boards specific needs and resources. A hub and spoke model is one example to mitigate this. This would see a service operating on 24/7 basis providing telephone/digital support to individuals in their neighbouring rural areas, with the ability to communicate with in-hours services in those areas.

7.11. Scrutiny and Oversight

The tier of support provided, the setting – whether hospital or community - and the staff employed will govern which Inspectorate the service should be registered with and the Professional Bodies responsible for upholding standards. This should be considered during the design of services.

7.12. Funding Models

There isn’t a single funding model for existing additional safe spaces. It appears that the tier and setting of support provided has great influence on whether the spaces are NHS, Health and Social Care Partnership or charity funded.

7.13. Conclusion

The evidence gathered during this exercise overwhelmingly supports the view that additional safe spaces are required, if we are to realise our ambition of creating a high functioning and whole system mental health service in Scotland.

As evident in this report, additional safe spaces are not a single space with a single purpose and must be designed to meet the needs of the individuals who will access the service. As well as meeting the needs of different populations groups, including those with protected characteristics, it is equally important that spaces are safe for people who need them and those people ‘feel’ safe and able to do so. As can be seen within existing examples of service provision, services must be designed for specific groups and deliver tiered support to meet people’s needs effectively and reduce the need for statutory measures.

Providing services within, or adjacent to, acute settings which allow for longer term assessment to determine whether care can be provided in the community prevents escalation to detention or voluntary stays in acute settings where a person can be better cared for at home with appropriate supports. It also allows for clinical support be in place for the interim period and smooth/semi - planned escalation to acute admission. Providing crisis care within community settings allows flexibility of access and service response, reducing service user stigma by providing a dedicated area for those to seek support without fear of being dismissed/and or treated unfairly. A common success factor is peer support provided within community settings, however; there are examples of peer support working alongside (rather than replacing) clinical staff, supporting recovery within hospital settings and the subsequent transition to community settings.

The involvement of local communities, service users and partners in the design of any new safe space is vital. This has consistently been credited as a common success factor from both services users and service users with regards to existing safe space service.

Support for this enhanced service from experts, services and people with lived experience has been unequivocal. New safe spaces have launched over the last 12 months with more scheduled to launch over the coming 12 months suggesting that this support is also reflected within local decision making and prioritisation of services.

Areas who are keen to establish new services should consider the role of Community Planning Partnerships (CPPs). CPPs focus on where partners' collective efforts and resources can add the most value to their local communities, with particular emphasis on reducing inequality and underpinned by community participation.