REHABILITATION AND RECOVERY SERVICE

OUR PHILOSOPHY OF CARE

Psychiatric Rehabilitation is a process of active change by which a person acquires and maximises the knowledge and skills needed for their optimum physical, psychological, occupational and social function. This is achieved by specific interventions that assist people recover from mental illness by improving role functioning, increased ability and/or decreasing disability and developing skills and resources that are specific to individual needs.

OUR SERVICE OBJECTIVES

To provide appropriate treatment and support, the service will strive to:-

• Enable people to live with dignity and independence and to direct their own lives.
• Enable people to regain optimum function and well being.
• Optimise self-care and autonomy.
• Optimise the capacity to communicate with other people.
• Minimise the disabling effects of mental illness and the impact of psychological distress.
• Minimise the need for formal and informal care.
• Maximise the appropriate use of health, social services, voluntary and community facilities including work, leisure and education opportunities.
• Maximise the opportunities for full participation in society.
• Maximise opportunities for living within the community by a stepped approach.
• To address areas of unmet need and to influence the planning and service provision for identified individuals.

ABOUT US

The Rehabilitation and Recovery Service consists of the following:-

Ward F
An 18 bedded mixed Rehabilitation Ward.

Ward 2
An 18 bedded male slow-stream rehabilitation and Continuing Care Ward.

Ward C
An 18 bedded female slow-stream Rehabilitation and Continuing Care Ward.

Ward 5
A 6 bedded Challenging Behaviour Ward.

OUR CARE

Our clinical approach is based on active treatment and Rehabilitation for patients with severe and enduring mental illness. Our philosophy is one of consistency of approach with the belief that positive change can be fostered and achieved for all individuals in our care.

The patients’ individual care plan is discussed and reviewed at weekly multi-disciplinary team meetings. An extensive range of Individual and Group Therapeutic Interventions are offered to meet patient need, based on N.I.C.E. Guidelines and Clinical Effectiveness, Evidence and Research. Individual progress and future need is reviewed through the Care Programme Approach and Unified Assessment. Various Assessment Rating Scales are utilised within all clinical settings in order to effectively measure change and to plan required interventions. The Tidal Model of care is utilised within all care settings.

Assessments undertaken within the Rehabilitation/Recovery Service cover the following areas:-

• Functional abilities, including living skills, educational and employment achievements.
• Social functioning.
• Psychiatric symptoms, cognitive deficits and relapse indicators.
• User and carer aspirations and opinions.
• Risk Assessment and Management.
• History of treatment adherence.

The service is based upon both in-patient and community Rehabilitation with close working between Cefn Coed Hospital, Cwmbwrla Day Centre, CREATE, Llanfair Hostel and Aberfa.

REFERRAL CRITERIA

• A written referral from the patient’s RMO must be received by the Rehabilitation/Recovery Service. The CPA/UA process should capture all of the information required for a comprehensive assessment of need and the care Coordinator should collate information to facilitate this process. A Multidisciplinary meeting on the referring ward will also take place to review the patients current status prior to a formal referral being made to the Rehabilitation/Recovery Service. This meeting must be held as part of the referral process.
• The Multidisciplinary team will discuss the referral during the ward round held on Ward F every Tuesday to determine the patients suitability for the service.
• A Comprehensive Assessment of the patient including current Risk Assessment and any Level of Observation must be included in the referral request.
• Evidence of Therapeutic Interventions already undertaken by the patient must be clearly stated within the referral request.
• All patients referred will be assessed by members of the multidisciplinary Rehabilitation/Recovery Service team.
• The patient’s Care Co-ordinator should discuss the implications of their transition to the Rehabilitation/Recovery Service with the patient and will continue to fulfil the role of Care Co-ordinator for the patient following transfer.

TRANSITION

Transition is the term used to describe the process involved in planning and bringing about transfer of care from one service to another. The nature and outcome of transitional care will depend on individual patient needs and views and should be based upon full and informed discussions between the Rehabilitation/Recovery Service and Acute Service, the client and carers.

• Patients will be accepted for a period of 6 weeks in the first instance as an assessment period for suitability to enter into a Rehabilitation Programme.
• During this period, the patient will be cared for by the Rehabilitation Team and will receive a comprehensive multidisciplinary assessment.
• The referring RMO will maintain clinical responsibility for the patient for the first 6 weeks including the Mental Health Review Tribunal process and any leave arrangements. However, the Clinical Team on the Rehabilitation Ward will assist the referring RMO by providing an addendum Review Report based upon the patient’s progress.
• The referring RMO will justify the patient’s referral to the Rehabilitation/Recovery Service in their Tribunal Report.
• Following this 6 week assessment period, another CPA review meeting will take place where the patients suitability for transfer to the Rehabilitation/recovery Service will be determined.
• If the patient is deemed to be suitable for a Rehabilitation Programme, RMO responsibility will be transferred to the Rehabilitation/Recovery RMO following a Section 117 or CPA Review meeting on the ward. It is expected that the referring RMO attend.
• A formal date for transfer of clinical responsibility will be arranged following Section 117 or CPA Review meeting and this will be made clear to the patient and their family/carers.
• The Rehabilitation/Recovery RMO will assume clinical responsibility for the patient and this will continue for 3 months post discharge.
• Following this period, the area RMO will take over responsibility following a Section 117 or CPA Review Meeting and then assume clinical responsibility for the patient.
• The Policy Guidelines for Transition to the Rehabilitation/Recovery Service from the Acute Service is enclosed ( Appendix 1).

OUR STAFF

The Rehabilitation and Recovery Team has an experienced and highly-skilled multi-disciplinary team consisting of:-

• Consultant Psychiatrist.
• Associate Specialist.
• Service Manager.
• Clinical Nurse Specialist.
• Ward-based Nursing Staff.
• Occupational Therapists.
• Physiotherapists.
• Advocacy service.
• Voluntary Sector.

The quality of any service is only as good as those who deliver it. In order to ensure that staff are equipped with the knowledge and skills necessary to deliver specialist care, we provide the following:-

• Comprehensive staff induction.
• Statutory training.
• NVQ programmes.
• Clinical Supervision.
• Specialist training programmes.
• Continuous Professional Development.

For further information, please contact:-

Mrs. Alison Guyatt, Service Manager, Tel: 01792 516514

Mr. George Twigg, Clinical Nurse Manager, Tel: 01792 516494