Service provision during the pandemic

Key points

• Services have continued to experience unprecedented pressure during the ongoing pandemic, which has placed additional burdens on staff. We heard that in many services staff were leaving for higher paid roles, or leaving active nursing because of burnout, putting additional pressure on the remaining nurses.
• With social distancing and other restrictions in place, services have had to balance a duty of care towards patients at the same time as upholding the principle of least restriction. Overall, we found that services rose to the challenges that this placed on their patients and staff.
• However, the combination of lockdown restrictions and staff shortages meant that many patients experienced a poorer service. This included, for example, limited access to leisure and therapeutic activities.

Nursing, medical and multidisciplinary staff, patients, relatives and advocacy expressed how well staff worked together to support patients during lockdown and how supportive management had been. Staff across the teams expressed being valued and enjoying their work.

Hartington Unit (acute adult), Chesterfield Royal Hospital, Derbyshire Healthcare NHS Foundation Trust, April 2021

The team had to adapt to multiple changes in light of the pandemic. In March 2020 the recovery ward was closed for a period of time, with staff redeployed to the two acute wards upstairs. On reopening, the ward has been used as an overspill for the acute wards, although it was not designed for this use [and] was not ligature-free.

Staff told us that the ward closure and changes to the ward remit had taken their toll on staff morale. Staff were highly motivated to work in a recovery-oriented setting and found the shift to acute care difficult. The staff team said they had coped with the changes due to a supportive ward manager, their team cohesiveness and mutual respect for one another. They understood that decisions had to be made regarding safe management of patient groups but did not always feel included in decision making that affected them or acknowledged for their efforts.

Acute ward, March 2021

Staff told us that the community mental health team staff had supported the ward onsite at the beginning of the pandemic when staffing levels decreased. This had enhanced both teams’ skill sets and improved liaison between the two teams. Staff felt that this had considerably improved the patient pathway from admission to discharge.

Juniper Ward, Bowmere Hospital, Cheshire and Wirral Partnership NHS Foundation Trust, June 2021

One patient told us that the, “staff are great” but that sometimes staff are not available when they wanted to speak to someone, for example if they were dealing with something on the ward. Another said there had been, “a few incidents of people kicking off and arguing… staff are good at sorting that stuff out… must be a stressful job, they handle it really well the staff are pretty awesome.”

Acute mixed gender ward, March 2021

Escorted section 17 leave was sometimes cancelled due to lack of staff. Although staff told us that they always tried to avoid postponing leave, one patient told us that twice they had arranged a walk with their relative as part of their escorted ground leave and the patient reported that their relative was already waiting in the grounds when it was cancelled on both occasions. The relative also shared similar concerns.

Medium secure unit, April 2021

Patients we spoke with told us there were very few groups happening on the ward and most of those that were had very little therapeutic value. One of the patients we spoke with told us that they rarely had 1:1 time with their named nurse since they had been admitted. The majority of the time their named nurses had either been off sick or on annual leave and no one had thought to reallocate them. They were also often allocated to bank or agency staff who they didn’t know. They also added that those patients who were openly displaying distress got the 1:1 time with staff.

Staff morale was low. The ward manager told us how staff had had to manage the pandemic, retrain and get used to redeployed staff, manage a few difficult admissions and move site and be up and running within 11 days. This had resulted in several staff needing referrals to occupational health and some had requested a temporary reduction in hours.

Carers and patients we spoke with felt that due to the lack of specialised eating disorder trained staff, the unit failed to deliver the service it promised to new admissions. Patients and carers felt that communication with staff was often poor. It was felt this was due to the few substantive staff trying to compensate for the bank and agency staff who didn’t know the ward and or patient group. A carer told us that sometimes it could take staff a week to return a call or email.

Eating disorder unit, November 2020

Staff told us patient acuity was higher than in the past and this combined with COVID-19 restrictions exacerbated and escalated situations. Staff felt some of the patients being admitted to the wards were not suitable for an acute environment because of the risks of violence they posed. They had cited incidents where police were called to support the ward staff … One staff member told us about an incident that they felt could have been avoided had the staffing levels been increased accordingly. They told us the patient’s behaviours had escalated throughout the day and it could have been predicted that there may be an incident. Staff felt that staffing levels should have been increased in light of the increased risks.

Acute male ward, March 2021

Use of section 17 leave had reduced as community facilities such as the Alzheimer’s café, the petting zoo and dementia-friendly arts performances were closed. Most patients were not physically strong enough to take extended walks, but staff did take individual patients out for car trips when this was feasible. Staff tried to increase on-ward recreational and therapeutic activity to offset the reduced availability of activities in the community. Occupational therapy and psychology input continued on the ward during the pandemic. Activities on the ward included sing-alongs, sensory therapy, hand-massages, art, music, baking and reminiscence therapy, as well as celebrations of special occasions.

Specialist neurocognitive/dementia care ward for men, March 2021

…in response to revised government guidance, Therapy Education Department (TED) staff were exclusively completing patient activities on the ward. We spoke with two TED staff who said they noticed patient engagement with activities had increased when they were based on the ward. They said the rapport they had with patients had improved and they had gained the trust of patients who previously did not engage with their team. The patient said he was happy with the level of activities on the ward and did not feel bored.

During the start of the pandemic therapy staff and therapeutic involvement workers (TIW) were redeployed to the wards across the hospital. All the staff commented on how the ward environment and morale had significantly improved. They told us the redeployment of this staff meant the ward had adequate numbers of staff to deliver activities to patients which in turn improved therapeutic relationships and outcomes. As a result of the learning from the redeployment the therapy staff have now set up outreach group comprising of therapy involvement workers, ward staff and technical instructors and occupational therapists to deliver outreach work to hard to engage patients.

Rampton Hospital, male treatment wards, October 2020

Although patients told us about music groups, art therapy, cookery groups and exercise, such as the gym and using the multi-use games area, patients also told us how boring it was on the ward recently. We were told that some days patients just sat in the communal areas not engaging in any activities. Patients told us how long the evenings and weekends were due to less activities.

One patient told us ‘they don’t meet my needs here… I walk around all day in circles like a trapped animal.’

Medium secure admission ward for men, March 2021

We heard about a range of psychological therapies available to patients. This included dialectical behaviour therapy and cognitive behaviour therapy, in addition to substance misuse and anger management groups. Several patients we spoke with told us they found these sessions helpful and looked forward to attending them. Patients also attended cognitive analytic therapy, which is a collaborative therapy that examines the way the individual thinks, feels and acts, and the experiences and relationships that underlie this (typically from childhood or early life attachments). We heard how this had been very beneficial for patients as it is a treatment that is person-centred and targets individual needs in addition to helping them to identify their own manageable goals for behavioural change.

Maple Ward (female low-secure), Waterloo Manor Independent Hospital, December 2020

The consultant psychiatrist and ward manager told us that the psychology input for the ward wasn’t sufficient to support patients in one-to-one sessions, group work and psychological assessments of individuals. They reported that staff also valued reflective practice especially at present due to the extra stress of managing COVID restrictions and the surge in patient numbers. They told us that one clinical psychologist was covering three wards so that [the ward] only had a psychology resource for one day a week.

Male acute ward, November 2020