Impact review 2013

A great highlight of my career! A menu of good ideas A much needed structure and focus A natural stepping stone A new energy Above all beneficial Affirming

Great fun
Happier clients and staff Have a laugh Huge fan Huge influence Improved their skills Inclusive Incredibly beneficial and worthwhile Innovative

Restored hope

Rewarding
Sense of achievement Simple So exciting!!! So human and humane.

So inspirational
Something for everyone

Amazing
An amazing response Animated Breath of fresh air Bright new idea Brilliant Brilliantly pragmatic Calming influence Changing the lives of inpatients for the better. Completely blown away Completely fantastic Confidence is growing Creative Definitely provides inspiration to keep going!

Spectacular.
"Speaks" almost personally to the staff member Springboard Stunning Talked my language Team building The best thing i've seen in ages Totally excellent Totally revolutionised our ward

Inspiration
Inspiring and invaluable Interesting Loved it loved it loved it. Magnificent Massive inspiration Morale

Do it

Easy to get going Effective

Motivati ng
Must have Normalises patient life Our bible Passionate and fired up Positive changes Powerful impact

Transform
Triumph Useful User friendly Using initiative Very accessible Very highly valued Very rewarding Very satisfying Wonderful
Wonderful and so accessible Worked wonders Wow, wow, wow!

Energised
Enjoying Everyones read it or doing it Excellent anchor Exciting Fab Fabulous Fantastic Fun Fun to go to work Good sound common sense

Practical ideas
Really beneficial Really enjoying it Really positive and energising. Really positive impact Refocus

Contents

1. 2. 3. 4. 5. 6. 7.

Background Questions and dilemmas What does Star Wards currently contribute to inpatient care? Impact review components Summary of survey findings Outputs and key numbers Survey a. What are respondents jobs? b. How long have they been involved with Star Wards? c. Whats it like trying to implement Star Wards? d. What has most helped involvement with Star Wards? e. Biggest barriers to involvement f. Whats happening on wards, and how much is due to Star Wards? g. Impact of Star Wards h. Awareness of Star Wards resources i. Talking therapies j. What else can we do to help? k. Anything else to tell us? 8. Media, citations etc 9. Behind the scenes a. Funding and support b. Marions mental illness 10. Appendix - Tangible results

1. Background
We knew from our previous impact review (2009) that Star Wards was definitely having a considerable positive impact on mental health wards. It felt crucial to know if this is still the case and to understand more about what is proving effective, with whom, why etc as well as the obstacles to taking part. Although there are all the usual reasons for assessing our impact (accountability etc), by far the most important one is for us to work out what we need to adjust given the very different circumstances now compared to when Star Wards began about 7 years ago. The situation on wards is both different to 2005 and to 2009. In some ways things are considerably better wards now have a strong expectation and aspiration to have a full programme of therapeutic and social activities 7 days a week and that staff should proactively engage with and form therapeutic relationships with patients. The progress was very apparent in the 2009 review as well as from Buddy and my many visits as well as more formal sources.

But then austerity struck and this has had a crushing effect on wards. Probably the most problematic development has been the axing of hundreds of inpatient beds over the last few years a BBC investigation in October 2013 found more than 1,500 mental health beds have been closed since April 2011, representing a reduction of 9%. This results in whats referred to in mental health wards as over-occupancy the prison phrase of over-crowding gives a clearer feel. On one of my admissions, there were 16 beds on our womens locked ward and 19 patients. Three women slept every night on sofas in the lounge, and about five patients were on home leave but without a bed to return to if they needed it. In addition, wards are having to contend with continuous reorganisations, the threat of job loss and indecently tiny budgets leaving almost nothing for staff development and support. The other part of the equation is that cuts in community services, employment and benefits are (obviously) having an appalling impact on peoples mental health and the deterioration of community support means that many people reach crisis, and hospital, before there is effective intervention. Two quotes illustrate the pressures wards are under, and the effect that has on being able to take part in improvement programmes such as Star Wards: Probably less of an impact than in years pastwe are mainly focussed on surviving, managing a basic service with much reduced bed and staff resourceless opportunity for service development. Yes, our focus is now squarely on the must-dosbed management, improving physical health, improving staff attitudesgetting ready for CQC visits, etc. Inpatient stays are becoming briefer A final factor which has made our work considerably more challenging is that the Department of Healths national structures for inpatient care, and the expert staff who supported these, have all been axed. This has huge implications for sector leadership (direction, motivation, information etc) and left an intolerable vacuum for inpatient specialists (clinical, academic, voluntary sector) to meet and work together. Weve tried to keep at least a semblance of a network together, creating NINE (National Inpatient Network Etc) but perhaps the name reveals my lack of enthusiasm for this role weve very reluctantly taken on. NINE wasnt included in the survey so Ill quickly mention here that although its just about functioned as a stop-gap network, meeting twice a year, it is inescapably limp without the national structure of civil servants and the regional network of regional clinical reps. It was that regional network that enabled us to get copies of each of our publications onto the desk of every ward manager in the country in our first few years.

2. Questions and dilemmas

We were pretty sure from what wed seen and heard that the survey would show that Star Wards is having less of an impact than a few years ago, despite (we believe) our resources and initiatives being of a significantly higher quality than in our earlier years. The prospect of having this confirmed was, nevertheless, dispiriting! On the one hand, if we were having insufficient impact, it might be best to close or put Star Wards on hold until a more favourable climate re-emerges. But conversely, really tough times arent when supportive projects back out. So this led to a series of questions:

1. How do we know what is good enough? As an outcome of our work? Wards work? Should we be looking for x% increase in recorded patient satisfaction? How would we judge to what extent, if any, Star Wards positively contributed to this? Is 1 transformed ward enough? 10? 5 wards improved but still a bit wonky? 50 wards improved but still...? 2. How do we know whether/what we should be doing differently? 3. Given the (unusual) constraints organisationally imposed by my mental illness (in particular around employing more people), to what extent could we do things differently? 4. How do we find out why wards/trusts arent involved? What else could we do to attract/motivate/help the weakest wards? Given that the survey findings turned out to be pretty positive, we stopped agonising about these, but they remain issues if not active dilemmas for us. However, looking at the tangible results and the following quote from the latest (October 2013) editorial in Mental Health Practice reinforces our view that Star Wards is still very much needed: Acute wards have witnessed huge improvements in the quality of care they provide, thanks to the dedication of staff and to innovations, such as the Star Wards programme.

3. What does Star Wards currently contribute to inpatient care?

Weve largely avoided getting stuck in a groove of only doing one thing there was SW1 and 2 but 3 turned into TalkWell and now the range of things we do is: Discover and share good practice (via newsletter, websites, Wardipedia, blogs, twitter and our 3 publications) Provide practical help via newsletter, websites, Wardipedia, blogs, twitter and our 3 publications Massively extend the impact of our resources through an appreciative, collaborative, coproduction, catalyst, jugaad (frugal innovation) model which motivates wards to share their ideas, resources etc with other wards. We produce things that make it easy for wards/hospitals/trusts to themselves design training (eg TalkWell training courses and forums!) Our just ideas ethos not only attracts staff to get involved, but they own wha t they create, making them more committed to it, the adaptations much more suitable for each ward/situation etc. Advocate for inpatient care (consultations, collaboration and tussles with other vol orgs, twitter, articles, conferences, NINE) Keep the inpatient experts networked (and hopefully help a bit with motivation) Improve morale among ward staff (appreciative content and tone of our work and communications, knowing Star Wards exists and is batting for them even if theyre not taking part, visiting wards, Full Monty). Reassure potential inpatients that most wards are safe and therapeutic. Establish high quality, usefully imaginative, realistic expectations of what inpatient care should consist of. Work collaboratively with the Care Quality Commission.

Two quotes from members describe the core features of our relationships with and impact on wards: Star Wards has helped us to further improve the experience of being an in-patient in [our Trust]. It has given us a framework for both leisure and therapeutic activities which are valued by service users and staff alike and is a growing force for channelling the enthusiasm and ideas of service users, frontline staff and carers. Through Star Wards, we have been able to recognise what we already do well; we dont do so well, and, what we could start doing again or for the first time. It also allows cross-fertilisation and adaptation of ideas and initiatives across older peoples wards, adult wards and the PICU. We aim to work on those aspects of Star Wards that need further development and to keep up our performance on all the rest. Patients that have had the experience of being in patients at different times during the period of time we have been working with Star Wards ideas have reported that their journey through this difficult time has been improved greatly and their experiences much more positive by the introduction and development of Star Wards ideas and all in all have felt that their stay in hospital a much more bearable experience.

The collaborative (even affectionate) relationship we have with wards is illustrated by a quote from a member of staff; It's nice to find out what's happening across the Star Wards 'family'. Examples include: There are Star Wards steering groups, champions, focus groups, noticeboards and even newsletters. Barnet, Enfield and Haringey Trust had an occupational therapist whose official role was to support the effective introduction of Star Wards Wards and hospitals have introduced a heartening number of initiatives which they badge as Star Wards eg: Sussex service user poetry books and Doing Stuff! - a guide for staff about running activities for male patients. In one trust, carers have been involved in Star Wards events, discos, film evening and a charity walk. We were told about the parents of a patient being delighted at the song he wrote about Star Wards!

4. Impact review components

The review has several components: Survey of ward staff (energetically encouraged through email reminders to our members, and less energetically via Twitter) Compiling information, since Star Wards start to now: o Tangible results (this is the first time weve done this) o Feedback from trustees and funders o Stats number of member wards, website visits etc o Citations academic, media, reports etc.

5. Summary of survey findings

The wards survey results were interesting and mainly reassuring. They confirmed our concern that there has been a drop-off of momentum and scale of participation, but reassured us that the wards that are still taking part do value and benefit from this. A few quotes illustrate this: I think in [our Trusts wards] Starwards has fallen off the radar and I don't think it feels high on the agenda for anyone anymore. I'm not sure what we can do to remedy this and it is a shame. It can sometimes be an uphill struggle implementing changes on a psychiatric unit but having the star wards has really helped as it gives us something to aim for and also gives the staff and patients a good range of ideas for activities and group work. When we became involved with Star Wards it was WOW. It still delivers the WOW. The website is constantly updated and its great to receive updates and to see what other wards are doing also and discuss and share these ideas.

A full(er) summary of the results is included in section 7 below, but the key findings are: Activities No impact = 7% Big or massive impact = 50%. Patient satisfaction No impact = 9% Big or massive impact again = 50%. Reduced aggression No impact = 21% Big or massive impact = 19% These are mainly similar to last time, but, delightfully, a surge of massive impact from 3% last time to 12% this time. (or between quite a big and massive impact = 26% this time, 34% last time. Or big or massive = 19% this time and 14% last time.)

Staff:patient contact increased No impact = 14% Big or massive impact = 29% More time for patient activities No impact = 20% Big or massive impact = 30%

Improved team working No impact = 14% Big or massive impact = 26% Improved physical environment No impact = 15% Big or massive impact = 39% Taking a longer time perspective, its clear that wards that are able to get involved find it a very motivating, structured yet highly flexible process for continuous ward improvements. Indeed involvement can be anything from dipping into Wardipedia for inspiration for a new activity group, to systematically working through all 75 ideas and achieving the Full Monty. Hearteningly, there continue to be a steady stream of wards (both NHS and private sector) gaining the Full Monty. This is the first time weve put together a list of tangible results (in Appendix) ward improvements which people have said is specifically due to Star Wards. Beyond all the other information, stats, quotes etc, we are particularly motivated by these hundreds of examples - from the vague but wonderful work is more enjoyable and rewarding to the appointment of activity co-ordinators, creation of resource rooms and, most importantly, much greater involvement of patients in their care and daily experiences. One development which were very aware of and excited about is the introduction of Therapeutic Liaison Workers in Leicestershire Partnership Trust. The role involves working alongside Occupational Therapists and Psychologists and other parts of the multi-disciplinary team and developing and co-ordinating ward-based activities. The introduction of the role has provided an alternative career progression to nurse training; most of the current TLW staff (pay band 3) were previously Healthcare Assistants (pay band 2).We keep up-to-date with this in a way we usually cant, as this was an initiative created by our very own Nic: The role really was a direct result of Star Wards. As the project was gaining momentum within the unit, Star Wards provided a crucial catalyst for the development of the TLW and ward activities. Thanks to its credibility, value and national reputation, Star Wards inspired us enormously and helpfully encouraged management to allow me to spend time developing plans for the role and implementing Star Wards ideas. The most recent development is that my Trust are investing a further 300,000 into this initiative. In the next few months, the Trust aim to recruit yet more TLWs (there are currently 8) making it possible to provide an activity programme which runs from 8.30am to 8pm 7 days a week.

6. Outputs and key numbers

651 wards as members although we know that many of these arent currently actively involved. Conversely, its been clear from the earliest days that many wards are involved but not members. As one respondent put it: Perhaps we are not officially involved... but we use the resources.

Resources o Star Wards website (including downloadable versions of all our resources, blog, Wardi-quote, library and benchmarking tools created by our members.) o 75 Ideas (including leaflet and wall chart) o Star Wards 1 o Two years of 4 page Star Wards feature, bi-monthly in Mental Health Today o Star Wards 2 o Festival o TalkWell o Wardipedia o Ward Buddy wards have downloaded this 3,000 times so far o 58 themed newsletters About 70 Full Monty awards presented Twitter about 2.500 tweets (some not about Buddy), 626 followers, Klout 48 We value our work with the Care Quality Commission who are astonishingly receptive to our views and the support we provide to wards. In development.. o Brief Encounters (practical resource for general i.e. non-mental health hospitals on communicating with mentally ill patients) o Ward Stars (validation scheme for healthcare assistants) o Resources for patients, staff and relatives of inpatients on young peoples wards and for learning disabled inpatients, staff and relatives o Removing obstacles (largely awareness) to having pets on wards o Networking faith communities, time credits, senior figures in the sector etc.

Website stats Analysis of website usage is surprisingly fun and detailed with Google analytics, and we do drill down regularly to see how many people are visiting which pages, for how long, Below are the average monthly visits and pageviews for the last year. (These figures take out visits of less than 3 minutes as its likely these werent of much help or, for the under 10 seconds, probably a typo caused by a film being named after our project.) Star Wards Visits 335 Wardipedia Visits 415

Pageviews 2,785

Pageviews 2,375

7. Survey findings in more detail

a. What are respondents jobs?
The respondents are most likely to be the staff most involved in Star Wards. The results are pretty much as expected ward managers are the key people on each ward, and the ward leader, while Star Wards is very OT-like, especially because the biggest thing wards pick up on is activities. About 10%ish are senior managers lead nurses, nurse consultants, modern matrons etc. Im surprised that the percentage of nursing assistants, activity co-ordinators etc is relatively low under 10%. Its possible that this doesnt fully reflect who takes the lead on these wards as it might be that a more senior person filled in the survey. (We could/should have asked what job the person leading Star Wards on the ward has.)

b. How long have they been involved with Star Wards?

The 43% who have been involved for more than 3 years is reassuring, although perhaps overrepresented in the survey i.e. theyre probably disproportionately enthusiastic and more responsive to filling in the survey.

c. Whats it like trying to implement Star Wards?

Whats it like trying to implement changes through Star Wards?

Great! Okay Tricky Nearly impossible! Not involved

So, pretty evenly balanced. One particularly interesting comment for us to contemplate is: We had a CQUIN around star wards - it really helped us to drive forward the structured activity programme The CQUIN payment framework is used by commissioners to link a proportion of English healthcare providers' income to the achievement of local quality improvement goals. Its clearly one way (albeit externally imposed which is so not the Star Wards ethos!) of ensuring that time, attent ion and resources are given to using our resources, implementing ideas etc. This comment illustrates the challenges but also the sustainability of impact even when wards are no longer actively or consciously taking part: Although our specific 'star wards' group has fallen apart (we tried to meet regularly and implement ideas from star wards but other commitments slowly took over), we have still managed to use
10

heaps of ideas, continue to consult and be inspired by the resources. Thankfully we have a greatly enlightened team leader and mostly enthusiastic team who are always looking out to better the experience on the ward.

Other comments included: The staff and service users are very enthusiastic and that makes things so much easier! Lack of resources and time can make it tricky As with any new initiative, staff are reluctant to engage with anything out of their comfort zone or out of the norm. Certain staff have embraced Star Wards and come up with new ideas all the time, sadly others see it as extra work. It can sometimes be an uphill struggle implementing changes on a psychiatric unit but having the star wards has really helped as it gives us something to aim for and also gives the staff and patients a good range of ideas for activities and group work. Implimentation using a baseline assessment was great. However maintenance has proven to be much more challenging. We initially were really engaged with it and had regular meetings, did ward based projects etc, but to be honest we haven't talked about Starwards or done anything related to it for ages.

There are ideas that are quite straightforward but some are beyond the control of ward staff especially those that involved funding and training. It was quite tough to find the time to set up meetings and look through what we need to achieve. It was hard that some of the criteria would not fit our low secure hospital and as a result we worked hard to ammend some them to suit our needs. We have got the book and have been using it as reference , however we are now really ramping up star wards in terms of day today actice

d.

What has most helped involvement with Star Wards?

In order of importance to wards: 1. Having access to Star Wards resources (eg Star Wards 1 & 2, TalkWell, Wardipedia.org etc) 2. Keen staff members 3. Patient input 4. Seeing the positive impact Star Wards has on the ward(s) 5. Support from ward management 6. Having a Star Wards lead on the ward(s)
11

7. 8. 9. 10. 11. 12. 13. 14. 15.

Support from Trust / hospital management Seeing the impact Star Wards has had on other wards Setting aside dedicated time Keeping it on the ward meeting agenda Getting the Full Monty award is an incentive Attending a regular Star Wards forum Having a dedicated Star Wards budget Having a Star Wards lead in the hospital / unit Other

This is deeply heartening!! Til now, creating resources has been by far the biggest input (and output!), its no surprise that keen staff members are crucial, and its great that patient input is recognised as being essential. Similarly, its lovely that people are motivated by seeing the positive impact of taking part. I am surprised that having a Star Wards lead isnt nearer the top of the list, but given that many wards dont/cant arrange this, its good that this isnt necessarily a major obstacle. Comments included: Having the star wards wardipedia and talkwell are great for myself and my fellow activity co ordinator colleague to refer to so that we can improve things on the unit and come up with different ideas to keep our patients motivated to join in with groups and activities each day. It would be great if maybe you send us a DVD or some kind of an educational info to promote the idea of Star Wards. Even better come Down Under! We have a star wards board on the ward and we also have a standing item on the community meeting agenda. Having Marion and Buddy talking about star wards to our pts was great. Unfortunatley my impression is that Star Wards has gone on the back burner a bit. other things seem to have become more important and these tend to be the must dos like our service reconfigaration, CQuins and CQC targets. This has motivated the staff and given them more confidence in taking the residents out and enjoying spending time away from the unit

12

e. Biggest barriers to involvement

What are the biggest barriers to your involvement with Star Wards? Please tick all that apply 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

Lack of staff interest

Lack of manageme nt support

Little or no money identified

Other priorities

No surprises, really. One comment was particularly interesting as it illustrates the pressures wards are under and the dedication of staff: Our main barrier in involvement with star wards is finding time in our busy days to go through the latest talk well and wardipedia updates as we work on a really busy unit with lots of different groups and activities going on and rarely find time to sit down at a computer to log on to star wards, which is why I find it easier to log on at home and forward any new ideas to my work computer ready to print off and go through at our ward community meetings.

f. Whats happening on wards, and how much is due to Star Wards?

What's happening on your ward(s)? 60 50 40 30 20 10 Ward Contact Library / Art Gardening Music Computers Physical Games (eg Talking Volunteer Access to Access to Sanctuary, Family and Access to Peer Systematic Systematic Other 0
Happening Happening because of Star Wards

13

Time pressures

Not sure where to start

Other reasons

Its hard to know how to evaluate this. It would be easy to feel disheartened, but: 1. Its complicated to ascertain what might or might not be because of Star Wards. The first comment given was: We do have lots of excellent initiatives and its difficult to say if some were in place before which is true of some but certainly starwards has helped with the process undoubtedly. For some issues, very close to our hearts, were having a good impact eg contact with animals (50% attributed to Star Wards), volunteer input (35%), peer support (50%), sanctuaries/chillout rooms (32%) 2. Over time weve had an impact on hundreds of wards so the cumulative effect of the things that are due to Star Wards is probably decent 3. These answers need to be seen in the overall context of what we know about our impact the tangible results illustrate this vividly. (Appendix 1). In terms of the specifics of what issues Star Wards seems to have most impact:
Happening because of Star Wards 4 10 11 3 7 6 6 8 7 2 13 3 7 8 7 4 10 8 6 0

Ward community meetings Contact with animals Library / books and magazines Art Gardening Music Computers and internet Physical activities / exercise Games (eg board games) Talking therapies Volunteer input Access to benefits and financial advice Access to recovery plans or workbooks Sanctuary, chill out or relaxation room (or similar) Family and friends involved and nurtured Access to visiting room Peer support (eg Buddy system, peer support workers) Systematic collecting of feedback from patients, friends and family Systematic involvement of patients in how wards / hospital / trust is run. Other

Happening 46 21 43 48 45 45 27 49 48 39 37 39 36 25 35 32 20 39 30 5

It was fabulous to see the following comment, as it illustrates something close to our hearts one of the most beneficial aspects of Star Wards is that it enables staff to take stock, to reflect on the (huge!) value of their work and commitment and to get a boost in pride and motivation: Writing it out now I realize that we are doing pretty well! Go us.

Some other comments:

14

We have been able to purchase a number of items as a result of the financial contribution made to us through star wards. It has enabled us to purchase a television set, books, games, a music system and CDs. We have inproved the environment through the purchase of art for the walls and doll to deliver doll therapy. On occassions we have had fish and chip suppers for the patients with a DVD night to follow, We are extremely grateful for the support that we continue to recieve. As an OT though me and the department here had many of these things in place before Star Wards. it was great seeing other professionals realising what could be done with a little time and imagination. Until Star Wards was made a priority, the biggest problem was lack of an Activities Coordinator as staff always complain they haven't time to do activities. Since we hired one lots more stuff happens on the ward, and the activity programme is a real and happening phenomenon. Also, the OT was hired at the same time and they make sure the star wards agenda is prioritised.

Star wards have been part of whole recovery process and have influenced change but couldn't say these things have happened just because of Star wards.

g. Impact of Star Wards

No impact Improved ward atmosphere Increased activities on ward(s) Increased patient satisfaction Increased availability of talking therapies Reduced aggression on ward(s) Increased length of patient stays on ward(s) Reduced the number of patients going missing Increased amount of staff-patient contact time Freed up time for patient-related activities Reduced staff sickness rates Improved team working on the ward(s) Improved physical environment of the ward(s) 5 7 9 38 21 36 51 14 20 40 14 15 Some impact 26 19 21 20 33 17 14 26 18 8 29 17 Quite a big impact 21 21 7 5 7 6 3 26 20 8 17 15 A big impact 23 23 42 18 7 3 8 19 15 5 21 29 A massive impact 16 26 7 5 12 0 0 10 15 0 5 10 Not sure 9 5 14 15 19 39 24 5 13 40 14 15

This is interesting, and reassuring! To take the key issues: Activities No impact = 7% Between some and massive difference = 88% Between quite a big and massive impact = 70% Big or massive impact = 49%. Lets say 50%.

15

Patient satisfaction No impact = 9% Between some and massive difference = 77% Between quite a big and massive impact = 56% Big or massive impact again = 49%. Again lets say 50%. Reduced aggression No impact = 21% - a bit down from 15% last time Between some and massive difference = 60% Between quite a big and massive impact = 26% Big or massive impact = 19% These are mainly similar to the 2009 survey, but, delightfully, a surge of massive impact from 3% last time to 12% this time. (or between quite a big and massive impact = 26% this time, 34% last time. Or big or massive = 19% this time and 14% last time.) Staff:patient contact increased No impact = 14% Between some and massive difference = 81% Between quite a big and massive impact = 55% Big or massive impact = 29% More time for patient activities No impact = 20% Between some and massive difference = 68% Between quite a big and massive impact = 50% Big or massive impact = 30% Improved team working No impact = 14% Between some and massive difference = 71% Between quite a big and massive impact = 43% Big or massive impact = 26% Improved physical environment No impact = 15% Between some and massive difference = 71% Between quite a big and massive impact = 54% Big or massive impact = 39%

We can also compare these to the same questions asked in the 2009 survey:

16

Table 1: Impact of Star Wards-related activities (percentages) (n=188)

No, not really A massive difference

Statements Improved ward atmosphere Increased activities on ward Increased patient satisfaction Increased availability of talking therapies Reduced aggression on ward Increased length of patient stays on ward Reduced the number of patients going missing Increased amount of staffpatient contact time Freed up time for patientrelated activities Reduced staff sickness rates Improved team working on the ward Improved physical environment of the ward

A little bit

Quite a lot

A big difference

Don't know

5.9 4.8 5.9

20.7 19.1 23.4

38.3 33 34

20.2 29.8 23.4

6.4 6.4 2.7

8.5 6.9 10.6

31.4

28.2

15.4

9.6

3.2

12.2

15.4 63.8

29.3 5.3

20.7 2.7

10.6 1.6

3.2 0

20.7 26.6

46.8 8.5 13.3

10.1 19.7 35.6

6.4 31.4 25

1.6 18.1 9.6

0 12.2 5.9

35.1 10.1 10.6

47.3

13.3

2.7

2.1

34.6

13.8 15.4

31.4 23.9

27.7 29.8

11.7 10.1

3.2 8

12.2 12.8

h. Awareness of Star Wards resources

A) Are you aware of Star Wards 1 Star Wards 2 TalkWell Wardipedia Starwards' website Ward Buddy Newsletters Star Wards or Wardipedia Tweets Marion, Buddy, Nic visiting Full Monty award 14 14 15 14 16 11 18 16 13 8 B) Have you seen 8 9 6 9 3 6 12 13 4 4 C) Have you used 14 15 15 11 20 25 7 14 6 10 D) Have you adapted 9 9 3 4 4 2 2 2 1 5 E) Not aware 7 7 13 15 9 9 11 9 24 23

17

So, quite a bit of scope here for increasing awareness! Less clear how to do this without bombarding wards, although posters would be great. A strange and possibly incorrect (or at least unrepresentative) finding is that Ward Buddy is already being used much more than Wardipedia. Anecdotal feedback suggests the exact opposite.

i. Talking therapies
We included this not because we are under any illusion that we could possibly be making an impact, but precisely because this is a long, slow haul and we need to maintain profile and pressure on the issue. We also thought it might be interesting for the British Psychological Society etc to have this info, however unrigorous it is.

Cognitive Behavioural Therapy Art therapy Psycho-Social Interventions Solution Focused Therapy Music therapy Dialectical Behavioural Therapy Other Drama therapy Mentalisation Based Treatment

Numbers 35 28 25 22 16 15 10 8 5

Percentage 41 33 29 26 19 18 12 9 6

j. What else can we do to help?

Most of the comments were along the lines of Keep on doing what you are doing!! Suggestions included having a national conference, cloning Buddy and me so were on every ward and visiting Australia!

k. Anything else to tell us?

Comments were mainly thanking us.

18

8. Media and other citations

We seek and get little media coverage. Til now, our primary relationship has been very much directly with the wards and ward staff (especially healthcare assistants) arent big readers of the sector press and our news is so niche that it would take a lot of effort to try to get anything in mainstream media. But we have a good relationship with Mental Health Practice, the Royal College of Nursings specialist monthly magazine for mental health nurses. Weve been heartened by the increasing inclusion of Star Wards in relevant reports, guidelines etc as this is important for maintaining our profile and credibility. Were also tantalised and somewhat frustrated that we know that there are articles about Star Wards in Trust magazines, newsletters etc, which is exactly where we need the publicity. But we havent managed to find a (time-efficient) way of discovering these. Some Trusts even produce Star Wards newsletters, eg this one from Northampton

There have been a few pieces over the last year or so which are particularly helpful for Star Wards, and arguably for mental health wards in general. The first was being included as an example in The Happy Manifesto , written by our management guru Henry Stewart of Happy. This was MAJOR for us! (The book is downloadable free from http://www.happy.co.uk/about/freepublications/register-for-happy-manifesto/ or http://bit.ly/iiiYB6.) Star Wards approach (particularly of trusting, supporting and equipping staff) is strongly influenced by Henry, who has been a wondrous ambassador for Star Wards as well as a continuous source of insp iration and practical advice.

Very significantly for us, there was an article by Philip Kemp and colleagues at South Bank University worked with North East London Foundation Trust to evaluate the impact of introducing both Productive Ward and Star Wards. Their article How to turn innovations into everyday practice was published in the October 2011 edition of Mental Health Practice (http://bit.ly/1afEnNC) and outlines some incredible achievements by NELFT eg:
19

The number of recorded incidents fell from an average of 30 per month during the first three months of the first year to an average of 13 per month during the last three months. And the average length of stay declined from 25.5 days to 20.3 days. Other remarkable service improvements included: service users reported being: offered more information when they arrived on the wards more involved in decisions about their treatments more occupied in useful and relevant activities respected more more satisfied with the care they received. new group activities were developed in consultation with service users eg carer support, health and wellbeing, and hearing voices, and a comprehensive programme of group activities now takes place on each ward. the development of a ward library, a gardening group and a ward-based internet caf, and the running of regular movie nights.

9. Behind the scenes

a. Funding and support
We are very very fortunate to have a group of funders who are wonderfully flexible, interested and supportive. This enables us, firstly, to devote almost all our time to improving patients experiences rather than being drowned in fundraising activity. Our independence (from the Department of Health, any one hospital or Trust or profession and from regulators) also means we are trusted by staff, patients, commissioners and regulators, and we can be very informal (i.e. friendly and human!), quirky and free-thinking. About 90% of our income comes from charitable foundations, who themselves cherish their independence and the ensuing freedom to innovate, take risks, occasionally fail, and to back effective but controversial projects. We are deeply grateful to be currently funded by: Esme Fairbairn Foundation John Ellerman Foundation LankellyChase Foundation Stone Family Foundation A big thanks also to our previous funders: Allen Lane Foundation (who heroically took the plunge as our first funder), Comic Relief, Javon Foundation, London Development Centre and to the Department of Health for s64 funding and support from the, greatly missed, NIMHE/CSIP. Its impossible to overstate the benefits that this flexibility provides. While we have a long list of projects wed like to do, our plans invariably change because wards come up with great new ideas or because one project sparks a connected one. For example, we wanted to create a version of Wardipedia (the best practice online compendium) for patients. This then morphed into a recovery companion, Ward Buddy. A ward for young people in Kent then contacted us to see if they could help us create a version for young inpatients, which were now doing. And working closely with a
20

young peoples ward (and the recent experience of a friend of mines 15 year old in hospital) made us realise the poverty of information and resources for young inpatients, their families and ward staff. We are exploring the possibility of a partnership with the highly specialist child mental health centre, the Anna Freud Centre. Most of these were not featured in our grant applications! But they are each, as far as we can tell, the most helpful thing we can do to improve inpatient experiences. Id like to report here that I am meticulous about consulting with (or at least informing!) our funders about the changes in plan. But Im not good about this and funders continue to be totally understanding and trusting. Some may wonder why we rely largely (90%) on grants from charitable foundations. In addition to the positive factors above (of independence and flexibility), the sad reality is that Im pathol ogically incapable of selling anything, so that rules out a social business model; we dont want to take money from pharmaceutical companies; and our sortie into mild commercialism, charging private wards 500 a year membership has brought in greatly needed income, currently about 9k a year, but only a small and sharply reducing number of private wards subscribed. (Everything is free online! The one real bonus of paid membership is that private wards can then take part in The Full Monty.) However, the one group of private hospitals which have continued to pay subscriptions is the Cambian Group. We are very appreciative of their support and energetic enthusiasm for Star Wards and even more so of the awesome services they provide. Our relationship with funders mirrors ours with wards and great managers with their teams and staff with patients. Its all about trusting, supporting and equipping people. Foundations give us all the leeway we need to be responsive to wards and provide us not just with funds to run the organisation, but also additional practical help and strong encouragement. Star Wards is based on appreciation for and trust in ward staff, so our role is to help with supporting and equipping them, in as flexible and responsive way we can. We are evangelical (and strongly influenced by the leadership guru Henry Stewart) about the need for managers to be trusting and supportive of their staff. (This was very much the year of the Francis Report, and weve made brief contributions to the debate.) Well-supported staff who have a strong sense of being valued and highly capable are then in a position to be a validating and trusted support to patients. A sort of serial sowing and reaping of trust, empathy and practical help from funders through to patients. We wrote to our funders asking for their views on our impact, as it is obviously essential that we know to what extent we are meeting their expectations. We had one reply and are very grateful to Eibhlin Ni Ogain from the amazing New Philanthropy Capital for her responses: 1. What were your expectations from your grant to Star Wards? We hoped the grant to Star Wards would support the core work of the charity and contribute to the stability of Star Wards projects. This is why the grant is core and unrestricted funding to be spent as Star Wards sees fit. 2. What was the most you were hoping for and what was the least? The most we were hoping for was that Star Wards continued the fantastic work it is doing for wards and complete the projects it wanted to, e.g. Ward Buddy and Wardipedia. The most we were
21

hoping for was the charity became more stable and continued to come up with and execute new ideas. 3. From what you know about the impact Star Wards has had on inpatient wards, how does this compare with your expectations? I think what Star Wards has achieved compares very well with our expectation (on the higher end). You have completed lots of projects and continue to come up with excellent new ideas. It never fails to impress us that you have an endless supply of new and exciting ideas and the contacts and networks to make them happen! We also think the last year has been a good year for Star Wards stability, especially with Nic taking more of a role and the support from external accountants. It seems to have been a very strong and stable year as a result. 4. What has particularly pleased you? Ideas for new projects (e.g. work with childrens wards), your endless supply of impressive contacts and Maudsley Hospitals new learning centre being named after Buddy! 5. What has particularly disappointed you? Nothing has disappointed us. 6. What has particularly surprised you? Your endless supply of new ideas and enthusiasm. Also your interest in making sure your work is still relevant and getting new ideas through a survey (as well as these questions) has been surprising but very impressive! 7. Is there anything else youd like to let us know? We always look forward to seeing Marion (and getting the excuse to have Buddy in the office!)

We are multiply indebted to Henry for his approach and the books that describe this; for Star wards being included in The Happy Manifesto and in Happy events (a highlight of the year for me was talking at a Happy Manifesto conference at Google HQ!); for his advice (on everything from Results Only Working Environment to how to use Twitter) and above all for being an incredible friend to me through the really rough times. OK, its getting a bit Oscarsesque with the thanks but just two more crucial sets Brights trustees are an exceptionally supportive, experienced, wise group, generous with their time and appreciation, sparing of additional admin and imposing advice. And above all, blessed with humour worthy of the best stand-ups. Finally, we are beyond indebted to the hundreds of staff and patients who so generously share their experiences, views and expertise with us and welcome Buddy, Nic and me into their wards and lives. We are bursting with admiration for their kindness and fortitude.
22

b. Nic
Gush alert! Its very hard not to get all gushy about Nic Higham who joined Star Wards last year. Hes a vastly skilled clinician (still working a day a week as a healthcare assistant on mental health wards), talented writer, creative thinker, Star Wards devotee, super-flexible colleague and, above all, utterly committed to truly therapeutic experiences for patients. Before meeting Nic, colleagues had responded very badly (and traumatically for me) to my illness and the self-destructive behaviour it provokes in me. The trustees and I were at the far reaches of caution about employing someone to share the work, but Nic was so impressive and so sussed about the realities of living with a severe mental illness that we took the risk. His expertise, imagination, patience and professionalism have transformed the amount and quality of what weve been able to produce for wards. Notably this includes his building our service user team the SU Crew. Paradoxically, and very unfortunately, I havent been able to work effectively with service users. But Nic excels at the thoughtful, creative approach that enables us to neither under-estimate peoples resilience nor over-burden them with inappropriate volume or deadlines.

c. SU Crew
We are very lucky to now have the input of a group of highly skilled service user associates, contributing to our resources with ideas, practical examples of great practice, and other input. Matt Moore is a highly regarded professional illustrator and animator and created wonderful pictures for Ward Buddy and is working on illustrations for Ward Stars.

d. Buddy!
Buddy is rarely behind the scenes Indeed, it is her presence on wards that is so cherished by patients. (Im only vicariously popular. Even having done a stand-up comedy course.) Before Buddy was my support dog, I found it very difficult and possibly inappropriate to chat to patients during my relatively flying visits to wards. But Buddy is the ultimate ice-breaker, with patients of all ages, in all kinds of emotional turbulence and distress. This is how Buddy is when meeting new people:

23

Patients know that Buddy isnt judging (or assessing or observing or worrying about) them, she brings happy memories of patients own pets and responds ecstatically to being stroked and made a fuss of. Very occasionally I get given chocs or flowers, but invariably theres a goody bag for Buddy! Buddys good-natured friendliness resulted in an extraordinary accolade. Thanks to our trustee, Geoff Brennan, a room at the Maudsleys gorgeous new learning centre, Ortus, has been named after Buddy. Here are the three of us at Ortus. (Geoff modelling what great ambassadors our trustees are for Star Wards.)

e. My mental illness
Ive tried finishing the review without including my illness, but this would leave a rounded consideration of our work glaringly incomplete. Im coming up to the decade anniversa ry of my illness (Borderline Personality Disorder) erupting, and although it wreaks much less havoc with my life now, it still greatly impairs my ability to function. Returning to the trust, equip and support theme, the trustees unswerving understanding and support have made it possible for me to manage my illness and run Star Wards. In particular, our chair, Ian Hulatt, is beyond saintly in his willingness to have identical conversations, weekly, about how many hours Im able to work vs what my work produces. One of the primary reasons that Ive been able to continue working through a very problematic and high risk illness has been the exceptional support Ive had from the NHS. My psychiatrist/therapist has maintained his trust that Im doing all I can to recover and that this will eventually happen. Ive had specialist weekly therapy on the NHS for seven years, but in our ninth year Ive initiated longer gaps and now have monthly sessions. In addition to this, for several (very rocky!) years I had an out of hours crisis therapist, paid for from a phenomenally thoughtful and generous additional grant
24

from Esme Fairbairn. Its perhaps worth pausing here. One of our funders, rather than feeling I was too high risk to fund, in addition to a generous grant to the project, also offered us an additional grant (of 20,000) to use if necessary to support my mental health. Extraordinary and deeply appreciated.

10. Conclusion
In our first publication, Star Wards, I wrote Were not seriously suggesting that any ward adopts all 75 ideas. (Although that would be good.) We were astonished and thrilled when almost instantly a hospital (Highgate Mental Health Centre) designed a template for benchmarking against all 75 ideas. And then wards got in touch to let us know that theyd managed to get all (relevant) ideas implemented many of these theyd already had in place but the structure had helped them to introduce many more improvements which benefit patients. The 75 ideas remain the backbone of wards involvement with us, but we have since developed all sorts of resources and initiatives which both complement and diversify from these. For us, Wardipedia is our ultimate resource a comprehensive compendium of great practice. This review has confirmed that we are still certainly having an impact, but less than in our earlier years both in terms of numbers of wards using our approach and resources and also in the extent of wards focus on Star Wards. The report covers how weve wrestled with this to work out what is the most helpful way we can support wards at a time when they are so overwhelmed. We concluded that: 1. We should continue! Id previously set up a short-term campaign to reduce the numbers of nonviolent offenders sent to prison which I then closed, as planned, after four years. So, rather unusually, I dont have a problem with ending initiatives which have done as much as they can. One of the most persuasive arguments for keeping going was in a response from one of our trustees who is a senior manager in a mental health trust. He wrote: Star Wards has achieved so much in a relatively short time, some initiatives have come and gone never to be seen again and Star wards is still there and strong as a product and meaningful initiative. 2. The recession wont last forever and when things pick up, its important that were still around to support wards. It seems that the (many) wards and trusts currently no longer involved are overwhelmed with the pressures of surviving and unable to focus on improvements. It doesnt seem to be because they didnt find Star Wards helpful (on the contrary) and this would strongly suggest they are likely to re-engage in due course when there is a reduction of daily pressures. 3. Wards that do use our resources unequivocally benefit from this. Were a tiny, lean (and keen!) organisation and thanks to our incredibly generous, committed funders we can be optimistic that we can continue to be of practical help to wards. We are able to be very flexible (again thanks to our funders) and respond not only to suggestions from wards (eg for a version of Ward Buddy for young peoples wards) but also to step back, review whats happening and change course considerably to be able to continue to be relevant to wards even in these highly demanding times. 4. Our approach, resources and initiatives are mainly time-neutral so could be in use in 20 or 50 years time. In other words, even with a decline in impact at the moment, we can be fairly confident that the work we continue to produce will have a long-term effect.
25

Continuing with the theme of sustainability, this is probably best illustrated with quotes from wards, showing different aspects of ongoing impact:

Although our specific 'star wards' group has fallen apart (we tried to meet regularly and implement ideas from star wards but other commitments slowly took over), we have still managed to use heaps of ideas, continue to consult and be inspired by the resources. Perhaps we are not officially involved... but we use the resources. Over the last two years since gaining the Full Monty Award we have strived to keep these ideals as part of the unit. We also display these ideals and our award on the unit and use these as a reference for internal audits and patient surveys. Star Wards impact remains much the same. Wardipedia is really useful and we are hoping to implement Ward Buddy on the unit soon. The impact still continues as it has from the start but also has improved with new ideas and activitys that has been going on Eg: New equipment for our Gym, More inhouse and outhouse activitys etc. The impact has not changed over the last two years. As a lead reviewer for the AIMS project with the Royal College of Psychiatrists I actively encourage other wards to use Star Wards particularly selling it to nursing assistants.

The Philip Kemp research mentioned in Section 8 had this to say about our sustainability: Structures and processes have been embedded in NELFT practice and will be extended to all inpatient facilities in the trust. Responsibility for the project practices has been transferred from the Star Wards and Productive Ward leads to modern matrons, and its outcomes have been incorporated into the trusts performance framework. In other words, the developments have become business as usual. So having decided that its important to keep providing support to the wards, weve carefully considered what we need to do differently to take account of these particularly fraught times. It feels like (most) wards are at saturation point with generic practical resources (i.e. applying to all wards) like TalkWell and Wardipedia. Were developing the following changes in direction: 1. Structures that help staff reflect on and provide examples of the incredible work they do. Ward Stars is a validation scheme for healthcare assistants who currently receive almost no training despite the huge complexities and responsibilities of their role. Ward Stars has a relatively simple structure for HCAs to notice and feel appreciated for all the professional skills and personal qualities they bring to their role. It has been endorsed by the Royal College of Nursing who are keen to help us promote the initiative. And in a stroke of great timing luck, the recently published Cavendish Review (into training and support for HCAs in health and social care) is a wonderfully appreciative account of HCAs work and dedication and is recommending a Certificate of Fundamental Care. We believe that Ward Stars fits in perfectly with the contents, spirit and recommendations of the Cavendish review.
26

2. Developing resources for specialist wards and/or patients on mainstream wards who have very distinctive additional needs. Were working with partner organisations to develop resources for young peoples wards and for inpatients who have a learning disability. 3. Rather than relying on ward and other hospital staff to create all the positive experiences for patients, weve started networking with other agencies who could potentially involve local people in satisfying, therapeutic and social opportunities. Weve begun working with Faith Action, a voluntary organisation for faith communities wanting to support local involvement with health services and service users. (On my first admission, there were no activities at all apart from once a week when members of a local church heroically came in for a singing and chatting session.) Weve also begun discussing with the charity Spice time credits people are rewarded for their contributions in credits which can be spent either within the group or in local places like cinemas, gyms etc. 4. Tackling mad rules. The worst is the rule that pets arent allowed on wards contrary to popular belief, there are no legal restrictions and there is a large evidence base for the benefits of pets for people with mental illness and in hospital. Buddy was able to persuade Rethink to choose pets on wards as one of their main initiatives following on from the Schizophrenia Commission, which itself strongly recommended wards having pets. 5. Getting a bit more political! Til now, weve largely left the campaigning (eg a bout levels of funding for wards) to our colleagues in the mental health voluntary sector. Now feels the time to join in and we have meetings planned with senior figures in the mental health sector. 6. Focusing on leadership. This feels timely, given all the interest in leadership following the Mid-Staffs disaster and the ensuing Francis Report, and our very fortunate relationship with Henry Stewart and Happy. We are continuing our core activities websites, visits, Full Monty, newsletter, Twitter etc. Were not sure what to do about the interim network we set up for inpatient experts (NINE) the meetings dont feel like the best way to meet the networking need and it might be that a social media forum, such as Yammer, works better. Finally, we remain confident about our working model, which fits many of the criteria for jugaad (a Hindi term for frugal innovation a creative or innovative idea providing a quick, alternative way of solving or fixing a problem) and all of the factors listed in the following piece.

An extract from Find the 15-Minute Competitive Advantage

by Rosabeth Moss Kanter, Harvard Business Review, Nov 2009
http://blogs.hbr.org/2009/11/find-the-15minute-competitive/

.. Call this the 15 minute competitive advantage: changing in short fast bursts rather than waiting for the breakthrough that transforms everything. If every proverbial 15 minutes, you learn something and incorporate it into the next speedy step, youll continue to be ahead. And a few time periods later, transformation will be underway Here are some characteristics of innovations most likely to succeed at gaining support:

27

Trial-able: The idea or product can be demonstrated on a pilot basis. Customers can see it in action first and incorporate it on a small scale before committing to replace everything. Divisible: It can be adopted in segments or phases. Users can ease into it, a step at a time. They can even use it in parallel with current solutions. Reversible: If it doesnt work, its possible to return to pre-innovation status. Eventually you want life to be unimaginable without it, but at least in theory, its possible to go back to ze ro. Tangible: It offers concrete results that can be seen to make a difference in something that users need and value. Fits prior investments: The idea builds on sunk costs or actions already taken, so it looks like not much change is involved. Familiar: It feels like things that people already understand, so it is not jarring to use. It is consistent with other experiences, especially successful ones. Congruent with future direction: It is in line with where things are heading anyway. It doesnt require people to rethink their priorities or pathways, even though of course it changes things. Positive publicity value: It will make everyone look good. These principles leave plenty of room to promote revolutionary ideas under cover of evolutionary change. But to find and grow a market for anything whether green products or new health delivery plans means staying close to what users can adopt easily and then leading them to the next iteration. Innovators who take risks must reduce the risk for others. Think long-term trends but short-term steps 15 minutes at a time.

Marion Janner October 2013

28

Appendix - Tangible results of Star Wards

The following are developments which wards have specifically said were due to their involvement with Star Wards. They are taken from emails, Full Monty reports, surveys and other feedback, from the time Star Wards was set up 2007. Although its a wonderfully heartening catalogue of ward improvements, we know that there has been considerable attrition and some of these achievements will now have withered or ceased. But we hope that wards which have experienced the benefits of taking part in Star Wards will, when circumstances are more favourable, resume their involvement. And our final section of quotes (Sustainability) also gives us hope.

Contents
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Philip Kemp research Staff satisfaction Patient satisfaction, involvement and autonomy Leadership by managers, ward staff and patients Improved staffing and resources Patient activities Supporting recovery Better relationships Improving the ward environment Involving family, friends and carers Contact with animals Staff training Star Wards as inspiration etc Star Wards as a structure, and structuring Star Wards activity Sustainability in UK and overseas

1.

Philip Kemp research

Very significantly for us, there was an article by Philip Kemp and colleagues at South Bank University worked with North East London Foundation Trust to evaluate the impact of introducing both Productive Ward and Star Wards. Their article How to turn innovations into everyday practice was published in the October 2011 edition of Mental Health Practice and outlines some incredible achievements by NELFT eg: The number of recorded incidents fell from an average of 30 per month during the first three months of the first year to an average of 13 per month during the last three months. And the

29

average length of stay declined from 25.5 days to 20.3 days. Other remarkable service improvements included: service users reported being: offered more information when they arrived on the wards more involved in decisions about their treatments more occupied in useful and relevant activities respected more more satisfied with the care they received. new group activities were developed in consultation with service users eg carer support, health and wellbeing, and hearing voices, and a comprehensive programme of group activities now takes place on each ward. the development of a ward library, a gardening group and a ward-based internet caf, and the running of regular movie nights. Hearteningly, the article had this to say about our sustainability: Structures and processes have been embedded in NELFT practice and will be extended to all inpatient facilities in the trust. Responsibility for the project practices has been transferred from the Star Wards and Productive Ward leads to modern matrons, and its outcomes have been incorporated into the trusts performance framework. In other words, the developments have become business as usual.

2.

Staff satisfaction
It always makes me smile. The enthusiasm about even the smallest things makes you think you're doing a good job, which is hard to do some days!
Trying to get resources such as an Activities Coordinator or exercise programmes has been a bit of a battle in previous years! Also, just coordinating the changes and everyone doing their part on time can be tricky. However, it's been an immensely satisfying experience for me and a great highlight of my career! The knock on effect is that work is more enjoyable and rewarding. It is an opportunity to learn and to develop new skills and knowledge. The best aspect of working through the ideas suggested by Star Wards was the satisfaction that the patient experience was being given a deeper emphasis through a nationally recognised organisation and that this fits in so well with the underlying philosophy of Occupational Therapy (OT). In forensic settings in particular, OT seeks to minimise institutionalisation and maximise quality of life, empowerment and independence, so it was felt that implementing Star Wards criteria would complement ongoing work and achievements in this area.

30

We have only just started this process and there isn't much to go on to help with a day hospital or memory clinic so we are making up the rules as we go. However my team are so motivated that it is at the moment a really enjoyable experience and its great watching them come up with new ideas and following them through to fruition. Our clients will really benefit. Star Wards allows us to be creative and use immagination. Its a great source of inspiration for all staff. More activities for our patients; it also gives staff a bit more structure to do activities with patients as our activities are protected engagement time; all staff know about this and facilitate this to happen. It has also meant that staff have become more creative in thinking about the variety of activities and events they can organise to make the stay of patients on our ward more comfortable. It has given staff more confidence.

Just again to let you know how much of a huge impact the star wards has had here and how i myself have enjoyed the whole process.
Better staff dynamics. A happier more optimistic environment for all. More activities for our patients; it also gives staff a bit more structure to do activities with patients as our activities are protected engagement time; staff have become more creative in thinking about the variety of activities and events they can organise to make the stay of patients on our ward more comfortable. It has given staff more confidence. Some have said that there is a real buzz about the place.

Seeing how units all over the country with diverse environments adapt to Star Wards to improve patient care.
Staff have also benefited from the activities programme. They have improved their skills and their confidence is growing in the running of most activities. They also have a sense of achievement, their relationships with patients have improved and they feel they are aiding patients recovery.

It cheers me up to know that there is good practice going on. I've never actually taken on an idea though the best ones come from within.

Some staff feeling that they are doing the job that they trained to do.

Really enjoyed using the online resources to implement ward activity where I work.

31

3.

Patient satisfaction, involvement and autonomy

Patients feel more empowered, this creates more motivation, improved relationships between staff and patients, staff and staff, less division, more optimistic attitude, improved mental health for patients and some discharges which I believe have happened sooner. It is helping the patients to socialise and it is great fun. For example we now have karaoke on the ward which is headed up by a patient. We even have patients from other wards who come and join us for this. We are all really enjoying it. Giving the service users the opportunity to participate in the star wards process encouraged and facilitated a sense of involvement, belonging and responsibility for service users. It was an opportunity for them to feel that their opinions are valued. We had our first meeting today with 4 patients, and practically before we started had loads of great ideas and comments flowing. It was fantastic to see it take off so naturally and easily and we have 4 actions to work on, all do-able by next week! We will have a weekly meeting, as part of our group programme. Relatives have commented on more activities. The last Mental Health Act commissioners visit commented on calm ward environment.

Increasing patient inclusion in care planning is definitely an area we have worked hard to achieve over the last year. As a unit, we use Star Wards to ensure that patients are involved in several aspects of their care. They have input into different activities, the unit environment (e.g. artwork) Star Wards helps patients to feel welcomed and at home on the unit. Star Wards encourages patients to become involved in several aspects of their care. It enables staff to see things from their point of view in order to meet their needs holistically Star Wards has had a great impact here in giving us more of an understanding on what our clients like/enjoy and also getting them involved and getting to understand there needs Its a good way in finding out our clients needs and a chance to get everyone involved in making their stay here a more relaxed feeling rather than a hospital setting. [Improvements have included:] o More person centred o Greater attendance (which indicates ? more interesting / appealing / enjoyable?) o Patients have a reason to get up on a morning o Patients are socialising more with others and developing supportive relationships o Greater links with community services and agencies who can continue to support upon discharge

32

o o

Greater stimulation / distraction All new patients provided with distress tolerance activities (e.g. word searches, colouring sheets, crosswords, self-soothe items).

A system for patient feedback - Points of You Daily community meetings and a personal patient profile with copies of care plans and a diary for appointments etc, along with ward information, advocacy information and other information Patients producing writing, drawings and photos about social and therapeutic experiences on ward, and displaying these. Wish List so patients can influence how OT budget is spent. Buddy system Community meetings at start and end of day has ended tension about financial incentives programme. Introducing therapeutic earnings. The daily community meetings and the use of the recreational budget to allow us to have DVD nights and have takeaways and have had positive feedback from the service users of how this has made a more integrated feeling between the staff and service users. Carrying on with the idea of communication, we have put up new notice boards on each unit. These incorporate the clients profiles and various client information. The clients decided that for their profiles they wanted short and concise points alongside their photograph so that any new staff could identify them quickly. The profiles are written in the clients own words and contain information about likes and dislikes as well as triggers and effective de-escalation techniques.

The clients get a sense of pride of having their photograph displayed and comfort in knowing staff will understand them better thanks to the work they have done. The notice board is maintained by a different client on each unit and they take care in ensuring that weekly activities, staff members on shift and upcoming events are displayed. Greater service user feedback (e.g. from activity planning meetings) which feeds into developments and makes it more service user led One of the ideas is day begins with ward community group. This was happening only on one ward. We introduced the idea over the other two units. It was difficult to get consistency at first but now the clients remind staff if the Nurse forgets to hold the meeting! Our clients decided they would only like a morning diary meeting and not an evening, so we went with this. The clients have fed back that they feel calmer

33

and more relaxed about the day ahead as by 9.30am each day they know what is happening during their day.

Another recommendation was related to ward meetings daily. This has been happening for a couple of years too and is terrific. It typically is one of the most attended groups and has provided a much needed feedback forum and an opportunity for clients and staff to get together and talk about how things are going on the unit.
Daily ward community group Implementing the Star Wards process has ensured that as a team on [the ward] we have reviewed how we involve patients on the ward and how they contribute to planning their care. It has demonstrated that they continue to be at the centre of the ward and has encouraged them to take more responsibility for making decisions on the ward. For example we introduced a Wish List so that service users have a say in how the OT budget is spent. Another example would be the Buddy system, allowing current service users to guide new service users through the initial stages of their admission, offering support, advice and useful information.

We introduced a Wish List so that service users have a say in how the OT budget is spent. The Buddy System provides the opportunity for new service users to learn about the ward and to feel welcomed on the ward by current service users. The move to a new ward can be daunting and anxiety provoking. Discussion about wrong payment and incentive levels during community meeting has stopped as patient are able to address this issues daily during start the day and end the day session. They feel that the team have true reflection of their engagement in treatment program.

Tomorrow we are starting daily community meetings and a personal patient profile with copies of care plans and a diary for appointments etc, along with ward information, advocacy information and other information.

We now have daily reviews of patient care by the Multi Disciplinary Team, firmly embedded as a given, from the Star Ward idea instead of our previous weekly review, which initially was met with some resistance from different members of the team (mostly medical) but this has now been embraced by all.

4.

Leadership by managers, ward staff and patients

Since the inception of the Star Ward initiative I have become more creative and innovative in the way I execute my role as a SHCA than before. I have made enormous contribution towards the achievement of most of the 75 Star Ward ideas. Clients running special interest sessions eg drama groups and productions.

34

Another example would be the Buddy system, allowing current service users to guide new service users through the initial stages of their admission, offering support, advice and useful information. Clients running special interest groups. For example, we had a client who was very interested in birds. We spend two weeks making bird cakes during a gardening project group, drawing and spotting birds during a nature session and creating bird colleges during an art workshop. This climaxed with the arrival of Falconry UK. They attended [our hospital] for an hour and gave the most interesting talk about Falconry. Having the star wards wardipedia and talkwell are great for myself and my fellow activity co ordinator colleague to refer to so that we can improve things on the unit and come up with different ideas to keep our patients motivated to join in with groups and activities each day. Leadership is vital.

The best aspect of completing the project has been patients exploring ways of improving their immediate environment, whilst creatively incorporating their skills and engaging in activities that they find meaningful. Some patients have really embraced the ethos of the project, and have been actively involved in taking responsibility for their own care and generating ideas on how to improve their stay within this setting.

Hopefully the new ideas have provided more opportunities for service users to access a wider range of resources (such as the ward library and ward internet access). This process has demonstrated that service users continue to be at the centre of the ward and has provided them with the opportunity to take more responsibility with regards to accessing the resources and making decisions on the ward. For example, the daily Planning and Debrief Meetings are chaired by a named service user who is paid for the role. Another example is that the wards recreation budget is spent according to the requests of the service users. With so many pressures now faced, at times we needed to work hard to keep it on the agenda and not loose sight of the positive things that could be gained from Star Wards. What pleased me most was how the team really thought about it, involved the service users, and were often willing to go the extra mile to help service users, for example one staff member changed his shift to take a service user to see a comedian at a theatre, even though it mean not getting home until midnight. Other staff will often come in early or stay late to go out with service users, to ensure that they are able to have as positive experience as possible whilst they are staying here. I believe one of the best ideas we have implemented is that clients run special interest groups. For example, we had a client who was very interested in birds. We spend two weeks making bird cakes during a gardening project group, drawing and spotting birds during a nature session and creating bird colleges during an art workshop. This climaxed with the arrival of Falconry UK. They attended [our hospital] for an hour and gave the most interesting talk about Falconry. The clients (and staff!) were able to hold a variety of birds and it proved the talking point in Walk and Talk for weeks! This idea really made us appreciate how important it is for clients to take the lead in sessions and feel empowered by their unique interests and skills. The most rewarding and fun idea we have fully embedded into the Activity Timetable is that clients run special interest sessions. One of the clients is keen on drama and hence we now have weekly drama sessions. The sessions tend to be made up of playing games and writing our own scripts! Since the

35

summer, we have put on two very successful productions. One was called Twisted this was a twist on Snow White where Snow White was evil and killed her Step Mother with the help of an imaginative evil dwarf! Our second play was called Spellbound (a comedy this time!) which centred on a good witchs love potion that goes wrong. Everyone who came to watch the production was astounded by the way that the clients performed. One client who takes several moments to answer a question was able to remember all his lines and talk with ease, whilst another client who does not interact very much with others did a sterling job of performing in front of a crowd. Hardly anyone could believe how the clients had led the sessions which led up to the production: script writing, directing, and learning of lines, team building and prop making. It was a team effort and the results were spectacular. Support from management has also been necessary and greatly appreciated, without this, time would not be dedicated to the projects and it would not be seen as a priority. Thankfully our management has appreciated the impact of Star Wards and encouraged us all of the way One thing that has been introduced by 3 of the healthcare assistants has helped to raise awareness of some aspects. They have implemented a regular session where patients can write a diary, draw pictures or display photographs about their social and therapeutic experiences on the ward. This will include community trips and sessions organised on and off the ward. These are displayed in the main corridor of the ward and will always be a work in progress, older items being removed as new ones are added. The patients appreciate being able to see their work on display and it is a reminder of some of the good times they have had on the ward. A recent seaside trip and summer garden party are new additions. Patients have really enjoyed writing about their trips and displaying their artwork in the corridor. They are very proud of the work they do and really appreciate having it on display. It is becoming a focal point of discussion for visitors to the ward and is helpful for newcomers to see the range of activities that they may become involved in. The patients are now also coming up with new ideas for additional artwork that they would like to have a go at and where they would like it to be displayed to brighten up the ward. It is nice to have such a positive response to this. We are very lucky that our organisation is a great supporter of Marion and all things Starwards etc

The ward administrator has helped to set up many of the new activities on the ward, and organise the weekly schedule. She says, This scheme is particularly great for patients who are unable to leave the ward. It keeps the patients busy, rather than them sitting watching television all day. Patients are constantly coming up to me asking me what activities are planned for the day. Service user chairs daily planning and debrief meetings a paid role.

Within the low secure service, one fantastic idea that came out of the Star Wards Patient Focus Group was patient-led skills sessions. It was discussed that many of our patients have exceptional talents and skills that others were interested in learning. We are now in the process of setting up this initiative and have patients who are willing to teach origami, sugar craft, baking, cooking, art, music and basic computer skills. We envisage that this project will have a positive long term impact on patients selfconcept by improving self-esteem, confidence and providing patients the opportunity of giving something of themselves in a safe environment.

36

Patients were enthusiastic about creating patient-led skills sessions where they could share their interests and skills with others. This initiative idea that is being developed and we have a number of patients who would like to facilitate sessions on origami, cooking, sugar craft, art, music and basic computer skills. By encouraging some of our most distressed and troubled patients to take the lead and ownership of new initiatives, we have seen a decrease in risk behaviours and a greater sense of community on what is a challenging environment to live in!

Our patients have been able to bring new ideas such as the new service user forum where service users discuss their problems with managers and service advocates. We have been implementing & benchmarking our achievements with regard to your brilliant initiative known as star wards for over 6 months now & the impact it has had on our unit is amazing. We are fortunate enough to have a patients council which is run weekly by ex service users enabling us to easily implement Star Wards suggestions. We also have a carers council who meet monthly & help us bench mark where we are at & lead where we are headed.

5.

Improved staffing and resources

Development of Groups/Activities Nurse role (me!). Particularly I would say the presence of an activity coordinator and having a weekly activity programme have changed patient experiences for the better. It makes life on the ward less tiresome and more dynamic, providing patients with an actual therapeutic environment, social interaction, learning of new skills and having fun! Also, the presence of an OT has helped to facilitate more home visits and leave plans, and ensure activity programme is going ahead, and is interesting and relevant for the patient group.

Others suggested that the main impact was providing a tool or new focus for the ward staff and for a few wards it included the development of new staff posts such as activity co-ordinators or the employment of occupational therapists. Appointed a staff member to work 10-6 3 days a week for Star Wards activities

. *we appointed a+ permanent activities coordinator.

Position of Activities Co-ordinator on the ward. Activities Co-ordinator.

37

Something I believe which has come as a great achievement as a result of the ideals has been the cross team involvement in activities with patients. An example of this can be seen in the activities that were initiated, developed and run by the domestic team and Head of Hotel Services. A member of the domestic team worked alongside the Occupational Therapist to develop a household skill focused group, which enabled the Occupational Therapist to assess individuals abilities as well as provide patients with professional advice from the domestic staff. In addition to this the Head of Hotel Service along with one of the Therapy Coordinators developed a group called Master Chef. The focus of this group was to be fully led by the Head of Hotel Services, providing sessions on topics that would teach skills specific to cooking beyond that of everyday cooking. Another cross team involvement has been the dedication of interest from one of the support workers for his DJing. This Support Worker has on several occasions hosted the music for some of our parties and celebrations. As well as playing the music he has also encouraged patients who have expressed an interest in DJing and provided them with 1:1 tuition during events. Non-medical staff much more involved in ward life. Our non-medical staffs have defiantly become planted in our daily activities with the clients. They are always invited to events and parties that we hold in the therapy centre. They often pop in when an activity is taking place or on the units just to join in and have fun! There is much more of a sense of togetherness now than there was 18 months ago. For example, we are holding a Christmas Carol Service later this month and lots of our team cannot wait to attend and join in (and eat the mince pies!). One staff member has even donated a Christmas tree for the therapy centre ready for the event. I believe the change in our practice has bought everyone together and boosted staff morale. The clients really appreciate the support from everyone who works alongside them and it is clear to see how much of a confidence boost they get from everyone wanting to support them in their recovery.

The major change has been how support workers and all staff across site have interacted in a more positive and creative way. For example, we put on regular drama productions and staff from housekeeping, admin and managers attended. I feel that there is a flare of creativity running through [our hospital] thanks to Star Wards.

Getting more staff involved and on board with the ideas eg. Holding community/carer groups and using bank staff to run activities. The process feels like a team effort. Increase in outside agencies involvement in group work.

More volunteers on the ward.

Far and away the greatest impact has been the recommendation of having up to 4 hours of peer volunteer time per day. This one recommendation has been transformative. Whereas previously we had about 4 hours per week we now have 30 hours per week of peer support (no longer volunteers, we have a paid peer support worker positions) in addition to which we have another 6 hours per week of peer

38

volunteers helping with activities. It is a rare week that goes by when some client does not say something about how helpful it has been to talk with one of our PSW's. Their presence on the unit also goes a long way towards reducing stigma as they are firmly entrenched in the 'staff' role thereby blurring the distinction between staff and clients.

As a newly established service, the low secure wards found that by working through the Star Wards criteria, we were able to identify much needed resources and have resulted in the establishment of a library and increased leisure equipment, including a pool table, swingball set and Wii Fit Board. It is important to mention that these requests were supported strongly by our line manager [Head of Therapies] who was both enthused and excited by the work we were doing and the Star Wards Initiative in general. We also developed a Patient Information Pack which contains information that patients within the focus group thought it would be useful for newly admitted patients to receive. This pack will remain with the patients and there are also sections where patients can store care plans, recovery plans and other documentation that they receive whilst in hospital. Star Wards was discussed in our community meeting. Volunteers were asked to meet up with the Assistant Psychologist to discuss the items we did not have in place (i.e. not having magazines/games in the Visitors Room). The group met up at the end of February and came up with a number of ideas about how to improve the Visitors Room including putting games in the room, putting their art work on the walls, putting up to date magazines in the room etc. They also suggested that it would be useful to provide all new admissions with distress tolerance activities (e.g. word searches, colouring sheets, crosswords, self-soothe items). We agreed to have a cupboard moved into the Visitors Room which patients could fill with games and jigsaws. The cupboard was moved into the Visitors Room. More recently magazines have been added to the Visitors Room. Daily community meetings and the use of the recreational budget to allow us to have DVD nights and have takeaways

During discussions we looked at the equipment that was available on the ward for people to engage in self directed activity. One of the areas lacking was music, an area which lots of people identified that they were interested in. We already had music to listen to and an old keyboard that was well used but lots of people played or wanted to learn to play the guitar. In partnership with the hospital league of friends we purchased an electric guitar, which sits in the general dining room/activity area and is used frequently. Its not uncommon to be working with patients in a group to a musical accompaniment. Ward library Internet access A wide and varied selection of games and books on the ward at all times. A library of books, CDs and DVDS in the ward, with up to date magazines , we also have an information stand and a health promotion area for patients, we have updated our board games and jigsaws and have a new Nintendo wii

39

The joint project with the hospital league of friends transformed a neglected and overgrown area into a pleasant environment to sit in and relax and created a therapeutic area to nurture and grow plants. It has provoked lots of interest from people who pass the area and become a talking point within the patient group. The fruit and vegetable growing has been a hit, with lots of fresh strawberries, gooseberries, apples and runner beans available for patients and relatives to keep and for use in cooking sessions. We run a structured gardening session on a weekly basis but people have been free to attend to general garden maintenance on an individual basis. Next year we are hoping to grow a wider range of vegetables and fruit, grow lots more plants from seed and have a party for the hospital volunteers to show them how things are progressing a year on.

I began by looking at resources and activities available to the patients on our ward. As the Occupational Department is located in a different building the patients had no access to board games, materials, books etc. I trawled charity shops, car boot sales and asked family members and friends to kindly donate their unwanted items. As a result the patients now have access to a wide and varied selection of games and books on the ward at all times. Creation of resource room with supervised internet access, Wii console and games and resource library. (Staff raised funds for above by completing sponsored canoe race). We have an activity co-ordinator and so need to increase the amount of resources and choice to the patients - in terms of one-to-one therapy time - this has been successful so far. The use of the Day Hospital facilities in the evenings and at weekends. The Recreational Hall made available for every Saturday and also two evenings per week. This further developed our range of activities to now include basketball, indoor soccer, badminton, table tennis, Wii, bocca, Velcro archery, curling and pool. There has been an increase in activities for patients on the ward. Due to the ward just being refurbished we have been able to obtain Play Station, Wii Nintendo, Snooker/Pool table and a table tennis table We now have a group room (thanks to Star Wards) where we play games, e.g Wii, take part in talking therapies, etc. This has led to many more activities taking place and increased patient involvement

New equipment for our Gym

Bought electric guitar

Supper & evening relaxation started. Ward laptop purchased recently, PAT dog visits.

40

6.

Patient Activities

Welcome Bags
The idea for the Welcome Bags came about from the information we received for the Star Wards Festival Celebration Bags which we actively took part in. A group was formed whereby the Festival Bags were made by service users from the East and West Willows wards and were sent away to London. During the festival bag activity group one of our patients asked if they could make their own bags to give to new patients on their ward to help them feel more welcome and dispel their own fears about being ill and away from home. The idea for Welcome Bags was adopted. It was suggested that we could scale down the original festival bag. Inside the bag would be placed a written information leaflet about the ward, a kind word greeting card, a timetable for on/off ward activities. Some patients would also put in a small sachet of hand cream, shampoo and hair conditioner, etc, thus making the bag a more personal item. The idea for the Welcome Bags were created. These bags are given to new patients from existing patients forming a patients mutual support system. This has helped with the well-being of patients who have been attending the welcome bag activity group. From the feedback that has been received they feel they are contributing not only to their own well-being but are showing the new patient that they care. Since starting this welcome bag activity group we have had patients approach us who have received a welcome bag and have requested to participate in creating their own bag to give to someone else who has just arrived on the ward. Many new ideas continue to pour in from patients as to what could be put into the bags. Important telephone numbers, i.e. PALS, Carers Support Groups, and appointment cards. During one of our groups one of our patients had finished their bag and was so happy and proud of her achievement that it was suggested she keep the bag for herself. No she replied, Ive made this for someone else to help them feel better. The message we are simply saying from these bags is WELCOME!

We have only been a Star Wards ward now for a few weeks and already the ward is a very different place. We have already introduced an art group, a DVD group, a walking group, a music and poetry group, we do karaoke evenings and have table tennis competitions. The project is about making sure we occupy the days of our inpatients with meaningful activities. We did some of this before anyway, but now it is much more structured as we have a planned weekly rota of activities which the service users have welcomed with open arms. It has helped us to manage aggression on the ward and is helping to increase engagement between staff and patients.

41

I looked at devising a questionnaire to seek patients opinions on activity provision on the ward....Through this we discovered a wide varied range of future activities that would become part of the weekly timetable. Interests included aromatherapy, dance, keep fit, art and crafts, non baking groups, walking groups, beauty classes, pampering and relaxation classes. We started a Walk and Talk group each morning between 9.30am-10.00am on our grounds so all clients could attend. This was a success during the summer but the sessions have stopped in the winter. The clients who are not on 1:1 observations have fed back that this was a great time for them to have a conversation and attention from staff. Any issues they had could be talked through and hence by 10.00am they were no longer upset or anxious over the issue. This proved to help clients settle for the rest of the day. Patient who attended one event (Olympic torch relay) stated it was the best day of his life!! In same group, service user was expressed her gratitude for being given the opportunity to watch the torch relay as she had taken the day off work several months ago (prior to becoming unwell) to watch this in her community and reported to have accepted he was going to miss it after being detained. Another idea which was client led was the monthly News4U newspaper. It was felt that there was a lack of communication between everyone at what was going on at [our hospital]. Achievements were not being recognised and no one knew what each other had been up to. The paper started as a team of two clients but soon nearly all the clients were contributing a page each to the paper. The paper contains information such as; what Education certificates have been awarded during that month, new clients that have joined us, clients who are moving on, clients pre-vocational adverts (e.g. advertising cards that they make for sale), sports, history and geography pages, puzzles and word searches and one month we even have a page dedicated to Klingon language! The paper is placed on every unit, in our library and a copy in reception. It has allowed clients to support each other in their achievements and to feel proud of steps they are taking in their recovery. Our Journey started about a year ago. We began by looking at the 75 ideas, and seeing which ones we were achieving or almost achieving. We spent time with the service user group who were here at that time, and asked them for their thoughts and ideas, from this we were able to identify and prioritise those areas that needed addressing first. Primarily these were the ones involving the resources we had in terms of DVDs books etc, and from the service user perspective relating to activities. From this two staff volunteered to co-ordinate the activities. So we now offer a number of activities that can be run as a group or individually Music, Gardening, Photography, Exercise/walking groups, Single gender groups, Arts and crafts, DVD nights, Healthy eating, healthy lifestyle (smoking cessation, alcohol awareness, healthy sleep, weight management), as well as specific activities for individuals, - swimming, cycling, introducing people to local facilities, day centres etc and local volunteer groups.

We looked at Star Wards and the benefits of, we also looked at the results of the patients questionnaire and through this we negotiated our working roles. We discussed a timetable that allowed OT activities, nurse activities and joint activities to take place, thus providing a more structured, creative, interactive and fun day for all the patients. Through time we furthered developed our resources. The use of the Day Hospital facilities were approved by senior management and made available to us for use in the evenings and at weekends. The Recreational Hall was also secured and made available for every Saturday and also two evenings per week. This further developed our range of activities to now include basketball, indoor soccer, badminton, table tennis, Wii and pool. Badminton racquets, basketball, indoor soccer ball and table tennis bats were purchased to facilitate our new activities.

42

I also sourced community links. I visited the leisure centre and found that patients on request can have an individual exercise plan devised with one of their trainers. A local community group have been an invaluable source providing tutors twice a week for educational and therapeutic activities. They have provided us with their programme of summer sample sessions and we have chosen activities for patients to attend. More activities done to suit individual interests. More healthy cooking e.g. smoothies, baking. Happier ward. Patients seem happier and look forward to external activities, e.g. walking group, cafe group, visits to parks and museums. Staff are happier seeing patients engaging more with them. Main changes is creating more ward based activities for both patients and staff to be involved. Observing Protected Engagement Time. Creating more links to community services. More available for patients not yet ready for community integration. More activities run by all levels of staff. Everyone is involved; warm atmosphere on ward; something for everyone. The patients have stated that there is a wider range of activities on the ward and that they have more input in the decision making of the types of activities that take place. This then has a positive effect on the staff. More activities and activities based upon choice. For example we have introduced more arts based groups and pilates sessions as well as psychotherapeutic activity. We also now have a dedicated activities co-ordinator. Staff feel happier that service users are getting a better service. Better engagement between them and staff. The meetings we have given them time to ventilate their thoughts about the ward and so far the meetings have remained constructive and they enjoy getting involved in improving the ward for themselves and other service users. Less aggression from patients, less boredom. More activities, especially evening & weekends.

In order to implement Star Wards, key staff had been meeting regularly to think about activities and share patient feedback across wards. In one of those meetings, the occupational therapist (OT) working on our rehabilitation ward highlighted the positive impact a reading group was having there. This group had been running on a weekly basis for some months, and the OT was keen to see such groups introduced in other areas of the hospital.

43

Thanks to Marion Janner of Star Wards. She may not know it (yet) but she has been wonderfully supportive throughout the development of Doing Stuff! *a guide for staff about running activities for male patients.] Like many staff I have always had a Star Wards type mentality, but it has taken someone like Marion to bring us all together to share experience and expertise. I am honoured to include the Star Wards logo on this pack, as without the inspiration of this initiative this would have been much harder project to get off the ground. Love the pointless national holidays from wardipedia I've added to the activity board is getting round everyone on Watermead. Saw Louise spending 'high five friday' giving them out to visiting CPN's and Patients! Patients happier and more busy The benefits of all these activities have been enormous for patients and staff alike. New patients to our ward believe these activities always happened. With re-admitted patients there has been a mix of responses. Some think these changes are for the better while a small proportion of patients just want to do what they always did on previous admissions, i.e. lie in bed. Holding community/carer groups and using bank staff to run activities. The process feels like a team effort. Love the pointless national holidays from wardipedia I've added to the activity board is getting round everyone on [the ward]. Saw [colleague] spending 'high five friday' giving them out to visiting CPN's and Patients! Walking group, cafe group, visits to parks and museums. More ward based activities for both patients and staff to be involved. Observing Protected Engagement Time. Creating more links to community services. Increased activities from OT on ward and more social/diversional activities, e.g. bingo, quizzes etc. PET (Protected Engagement Time) introduced. Cafe walks, market walks and smoothie hours. Attendance at patient community meetings has increased. More requests from service users to introduce more activities such as swimming and cooking groups. Day starts with community group. More activities on ward (structured day).

An increase in the variety of activities especially outside of the hospital, e.g. walking groups, cycling, swimming. Concerts in hospital, professional musicians coming in and performing...High level of compliments received; between 130-140 hours of activities available each month; number of days with ward based activities (100% every month); % of activities outside mon-fri 95 (100% every month).

44

When the weather is permitting, I and other members of staff we take service users to restaurants either on their birthday or on special occasions, car boot sales, car shows, fishing, fairs and also introduced some of the services users to flower planting in the wards garden. I have an active role in promoting and encouraging service user to pursue their leisure interest despite their leave conditions and risks. We do play pool with service users and other games. I am grateful that the Charity Bright has brought up this Star Ward Initiative which is very effective in enhancing service users recovery irrespective of their circumstances. More evening activities. More 'event' type activities such as regular inter-ward competitions. More involvement of outside organisations. A wider range of activities on the ward and patients have more input in the decision making of the types of activities that take place. This then has a positive effect on the staff. Reading group

Staff and patients doing DJing

More in-house and out-house activities etc. Patients complain less of boredom, and look forward to particular activities. More interaction with the patients, doing more normal things together. More activities, especially evening & weekends. Development of Groups/Activities Nurse role (me!). Supper & evening relaxation started. Ward laptop purchased recently, introduced an art group, a DVD group, a walking group, a music and poetry group, we do karaoke evenings and have table tennis competitions.

7.

Supporting recovery

Recovery Bracelets
We were in a Star Wards meeting planning the Recovery Folder (a transforming Star wards idea) Launch event. We were thinking of ways to promote the event and three key people ideas came together. Our activity coordinator (another transforming Star wards idea) spoke about the creative use of colour and two other, Amy our senior practitioner and Sean our service user who wrote the Star wards news letters generated the bracelet idea and how we could use colour to convey Recovery. The group, and patients in OT made 100s of the bracelets and we gave them away at the launch event. Because they were so popular we started to think about how we could sustain it in the long term. At this 45

point we handed the idea over to our vocational rehabilitation services and there a group of services users created new designs and the second generation of bracelet was born. They produced the brochure, based on our original designs. This is paid work for the service users. We now have little do with the project other than to give them lots of support and have a nice warm smile every time we see someone wearing them. It is a perfect example of how two very different services can work together, but Star wards was absolutely the inspiration behind it.

Patients are offered a range of recovery tools and are encouraged to pick one that they feel suits their needs. They are supported to complete this with their named nurses during protected sessions. Range of recovery tools

We have developed a recovery pack which we give to all service users on admission with a range of selfcare tools including creative writing exercises to develop an alternative construction of self and this also covers a range of star wards standard The new Ward Buddy scheme has also been an important factor in the implementation of the [patient guide] for new patients admitted to the unit. It has given myself and the Assistant Psychologist the opportunity to train to facilitate a Hearing Voices Peer Support Group on the Ward. This is a very exciting project to start on an inpatient ward. Development of a recovery folder for patients. Daily Planning meetings.

Yes, patients have a more fulfilled therapeutic timetable, have increased access to a variety of activity, and are involved and given the opportunity to engage in mapping their own recovery (Recovery Star) We are able to facilitate more escorted leave around the hospital grounds on into town because of the presence of activity coordinator and OT. This has gone down very well with patients, many of whom now get out on a walk everyday and the feedback regarding this helping their overall recovery, is very positive. Physical exercise programmes Exercise therapies; Complimentary therapies; Community meetings; Protected Time.

Patients on request can have an individual exercise plan devised with one of the local leisure centre trainers. A community adult ed group providing tutors twice a week for educational and therapeutic activities.

46

Daily reviews of patient care by the Multi Disciplinary Team

Increase in outside agencies involvement in group work. Physical exercise programmes available. More of a variety of activities e.g. crystal/colour therapy; jewellery 6-week course; Belly dancing course; pets as therapy; creative groups; internet access; more games; access to gym and healthy living group.

Patient who attended a full day of activity (including independent living skills group, recovery group, think about it group and Evening Dinner Group reported it has been the best day of her life as she had never been so productive with her time and thoroughly enjoyed it!!

A carer commented recently that her relative become more socially engaged since being admitted on the ward. Carers commented on the willing of some staff members who engaged their relatives in meaningful activities.

One patient has spent many years caring for her very elderly husband with intense nursing needs, and because of this gave up many hobbies and interests she used to have. This led to severe depression and suicidal thoughts. On the ward she has now had the opportunity to re start her hobbies of gardening and exercise and participates in the gardening group and chair aerobics sessions we have on the ward. This has given her a new lease of life and she hopes when she is soon discharged, to continue these hobbies at home and in the community, as husband is being placed in nursing care (The hospital gardener/OT also has a community gardening group this patient can attend on discharge.)

Also, the introduction of a monthly themed market stall that is hosted in the interward room provides the opportunity for service users to develop a vocational role and to be involved in all parts of the process of preparing for the market stall (e.g. baking cakes, making soup, making the poster, serving customers and handling money).

One of the ideals inspired the development of a therapeutic earnings position, which utilised a patients skills and interests in art and design, to create activity posters for the hospital. This made a difference in being able to identify patients natural talents and interests and honing in on them to be utilised in such a way that was not only practical but of achievement also. The older adult group feel it reduces their social isolation, and are more confident to engage in community resources after discharge. Service users looking forward to getting involved in the activities with the staff identified as being friendly.

47

A relaxation programme was also sourced and implemented on the ward.

A relaxation programme

Healthy living days

We are currently running supper groups and after discussions have now decided to make these days healthy living days, with fresh fruit available for all on this day with walks etc available. It was agreed that providing all patients with a generic set of distress tolerance activities would not be useful as individuals needs for distress tolerance activities differs markedly. It was acknowledged that having a centrally held box of distress tolerance activities could be useful when individuals are struggling. This idea was discussed with the patients and accepted. Patients have planned to use the games in the Visitors Room for when befrienders come to visit them. Patients have also proactively engaged in the project. They have been very willing and proactive in coming up with a list of items to go in the Coping Skills box and are keen to ensure that the box remains stocked up.

The Star Wards champion applying for money to purchase a range of beauty and hair care products so that the wards Beauty Group can expand. This initiative is a response to patient feedback that Beauty and pampering sessions not only improve their self-esteem but also make the ward environment even more relaxing and enjoyable and build the sense of a homely, caring ward community.

Buying beauty products to extend Beauty Group The feel from patients is that of a much more therapeutic and recovery focussed treatment process.

8.

Better relationships
Nine adult acute wards in [our] Trust have registered on the star wards programme and are implementing a far reaching programme of improvement across the wards. One of the successes of implementing star wards is that service users and staff are coming together in a really meaningful way to improve the quality of care provided. Staff make more of an effort to engage patients in planning activities or themes on wards. An increase in activities and more engagement between patients and staff. Community meetings.

Reduction in aggression from clients. Less conflict /aggression. Less AWOL.

48

A small number of staff suggested there had been reductions in conflict incidents including aggression and patients going missing from the ward.
The ward library had previously been a shelf of books available to patients to borrow as desired, but had seemed quite unused. Through the Star Wards initiative, [OT] managed to persuade two patients to help re-establish the library and work together despite the two patients previously avoiding working with others. They have now both told staff that it has felt really nice to have a role.

*It has given us+ us more of an understanding on what our clientslike and enjoy and also getting them involved and getting to understand their needs. Its a good way in finding out our clients needs and a chance to get everyone involved in making a more relaxed feeling rather than a hospital setting. Staff more involved with patients (staff available for 1:1 sessions at any time). The ideals offer a broad range of initial ideas for the development of services, which inspired the creation of a much broader range of activities here. As a result we saw a change in the level of engagement, reaching the interests of patients who are hard to engage. More activities; more time spent with nurses; structured day; less aggressive episodes on the ward. Better staff dynamics. A happier more optimistic environment for all. Interaction has increased due to activities that have been set up on the unit Often linked with increased activities but sometimes as a separate category, staff spoke of increased and improved staff-patient interactions and patient-patient interactions. Also frequently interlinked with this were improvements in staff morale, improvements in patient satisfaction and quality of care, less boredom and improvements in ward atmosphere and environment. Much more going on on the ward which have improved relationships between staff and patients. Improved engagement of patients with activity and rehab. Less incidents. We've had loads of good things happening on our ward since I came back from the festival all inspired. A new suppertime group followed by relaxation (pyjamas welcome). Also we have started Protected Therapeutic time in the mornings. All good stuff. Star Wards help build relationships with patients and therefore help build trust. This increases patient and staff interaction. SW also helps deal with patients' problems, e.g. stress awareness, anger management. This also has a calming influence on the ward as a whole.

49

9.

Improving the ward environment

We now have a group room (thanks to Star Wards) where we play games, e.g Wii, take part in talking therapies, etc. This has led to many more activities taking place and increased patient involvement, staff are taking part and enjoying the increased activity. Patients are not as bored and therefore not as resentful or aggressive. The ward environment has been transformed into a homely and pleasant atmosphere: antique tables with pot plants, additional pot plants and flowers have been neatly arranged along the ward corridor. Purchased pictures which I have artistically mounted on the wall. Cinema viewing at least once a week . We do borrow DVDs and view then in a specially selected room. In discussion with patients, and staff, it became clear that they wished to have a room that provided tranquillity and relaxation during times of distress. Through exploration of their ideas, they suggested decorating a quiet room on the ward. A focus group was set up on the ward, inviting patients to share their ideas on how this may be achieved. A subsequent art group was offered in which they sketched images for review and decided upon an image of a lake/mountains and an under the water theme on both wards. Patients within the art group have participated in painting this image onto the wall and it looks fantastic! They have worked collaboratively to support each other, regardless of skill/ability. A chill out room - The chill out room has been the biggest success so far! We had our visiting area in our dining room area which was not very private, but the ideas from Star Wards gave inspiration for improvements to the environment during out refurbishment stage which meant that visiting areas were closely looked at and incorporated when these changes were made and we now have several private areas for our patients to receive their visitors other than their bedrooms but we now also have a family room offset from the ward that is suitable for children and other family members to visit patients without the influence of the ward environment which is not always a quiet and peaceful place for family to visit. Improved physical environment eg more private and meeting rooms designed during refurbishment transformed a neglected and overgrown area into a pleasant environment to sit in and relax and created a therapeutic area to nurture and grow plants. Myself, the ward manager and staff and the patients have taken on some of the ideas from the suggestions list and have now got a library of books, CDs and DVDS in the ward, with up to date magazines , we also have an information stand and a health promotion area for patients, we have updated our board games and jigsaws and have requested and received an Nintendo wii which everyone is enjoying. New noticeboards.

50

My friend works on an eating disorders unit and she has just started looking at star wards, the first thing she did was to go out and buy some nice mugs for the patients, a small thing but so homely!

There is a more homely feel for our clients.

More pleasant atmosphere and improved decor. Ward looking good. New projects: therapy garden, revamp cafe into 'Lilly's Tea Room'. Patients that have had the experience of being in patients at different times during the period of time we have been working with Star Wards ideas have reported that their journey through this difficult time has been improved greatly and their experiences much more positive by the introduction and development of Star Wards ideas and all in all have felt that their stay in hospital a much more bearable experience. I have made some initiative in improving the ward environment in a number of areas with very positive results. The ward environment has been transformed into a homely and pleasant atmosphere. This was done by obtaining side and corner antique tables on which pot plants are placed on to give the ward a pleasant outlook. In addition to this, additional pot plants and flowers have been neatly arranged along the ward corridor. Through support from the MDT, the ward has purchased pictures which I have artistically mounted on the wall. To enhance, the service users experience in [our] Ward, I am working with them (that is those who are interested) in organising cinema viewing at least once a week . We do borrow DVDs and view then in a specially selected room. In conjunction with this, we are aiming to furnish the rooms accordingly. Once completed, this room will be an area that patients can use readily for reflection, relaxation and therapy sessions.

10. Involving family, friends and carers

Carers have been involved in several Star Wards events, discos, film evening and a charity walk. The ward appears friendly, fun, environment. Good distraction [for visitors] from the stress of loved ones being unwell and creating an upset environment. From the ideas of nurturing links with family and friends, we now as a standard offer family/carer meetings and have carer care plans in place and a system for patient feedback that is called Points of You, which we actively seek feedback from patients and their families so that we can strive to continue to improve the whole experience of a hospital stay. Yes, activities are well received and as we work on a mother and baby unit then we do offer activities/support based groups with fathers and other relatives. Family/carer meetings and carer care plans

51

Parents of a client loved the song he wrote about Star Wards. Family are happy that there are activities for their families on the ward.

Visitors have noted and commented on our Star Wards board saying that they are impressed with the activities Star Wards is introducing to the ward.

Visitors who have come to the ward (relatives) are happy to see their relatives engaged in activities, e.g. relatives see them playing board games, puzzles or engaged in creating art and seeing it displayed on the ward. Visitors are extremely encouraged by the carer groups that are now running.

Star Wards has enabled us to continue with this process of continual improvement and has given us a structure to work within, enabling us to easily audit our successes, identify plans where we need to improve and most importantly capture and make use of the creativity and energy of our service users, carers and staff. Our monthly Acute Care Forum and various other groups such as the Carer Link Group and ward community meetings are used as the vehicles to listen to service user and carer needs to try to better meet the requirements of Star Wards.

Visitor feedback forms - they like the new library/IT suite.

Families and outside agencies have commented that the atmosphere on the ward is less tense.

Enhancements to visitors room (games, artwork on walls, current magazines)

Have had visitors attend ward events such as disco's and film evenings always to a positive response.

11. Contact with animals

Since I emailed you I had a close look at our Trust policy re staff bringing in their own pets to visit as I have a colleague with a lovely little dog and she is willing to loan her out to us once a week.

PAT dog visits.

52

We were lucky enough to have a Falconry show visit us and it was a fun afternoon spent by all. The clients and staff were given an informative talk about different birds and we were able to take turns in holding a variety of birds. For some clients it has been a while since they have seen any other animals and it was the talk of our daily walking group for weeks! Member of staff bringing her dog weekly

The biggest achievement though, although it sounds quite trivial, was getting Mary, our cat. We were adopted by a cat, which used to just turn up! Some service users began to feed her and you could see the pleasure it gave people. However it was felt that we needed to find out if she belonged to anyone and took her to a local vet who confirmed that she was tagged. She was therefore reunited with her owners. However at the end of that month, I had the best response ever for our Points of You, everyone put in a card asking if we can get a cat. We contacted a local cats home, who were able to match us up with our Mary. She is very much part of the team now and everybody takes time to talk with her, feed her and stroke her. Patients' now access and care for animals. Animal-assisted therapy - pet lambs have been a great success also.

Lilly dog is now a regular visitor on the ward, and is lapping up the attention she receives from 2 wards. It would be fantastic if [our ward] were to gain the Full Monty Status, which would reflect and evidence the good work that is already done. I look forward to meeting both of you in July. Unfortunately Lilly dog will not be able to meet you both; she is a diva and would most probably get jealous of Buddy being in the limelight.

12. Staff training

TalkWell is currently being implemented and staff along with patients are being trained by psychology department. This is the next big initiative that we are driving and aim to have every staff member going through the work book and training. In response to requests for more time and access to TalkWell training, the Trusts MAPA (management of actual and potential aggression) team have agreed to include TalkWell in their five day training programme, which is accessed by all new staff, all bank staff and all community staff in the Trust. TalkWell are given out to all staff that undertake the training and are handed out in goody bags on improvement days to raise awareness among the staff within the Trust.

53

It gives us opportunities with staff and patients for discussion on how we improve the environment for the patients in our care for an enhanced stay and experience.

We have used Star Wards literature as educational classes with staff at times as it gives focus and understanding on patients experiences.

TalkWell being used on university mental health nursing courses.

By co-incidence I was doing a de-escalation session with students from the [hospital] today who are just at the end of their second year of training so I referred to [TalkWell] several times, giving StarWards a really big plug as I did so.

I have been running Talkwell workshops here for our non-registered staff. Have had 100 attendees over last couple of weeks and it has been well received. I have also set up a Talkwell forum on suggestion of some of the attendees - to meet up every six weeks to keep the spirit of the training ongoing, for people to reflect and to share practical ideas. It's going to be run on an open space approach. On a personal level, I haven't enjoyed anything at work so much for ages. I have shown the TalkWell package to [a colleague] a few weeks ago with a view to using it as part of the commissioning process for 2010/11 for Trust staff training in therapeutic communication. In response to requests for more time and access to TalkWell training, the Trusts MAPA (management of actual and potential aggression) team have agreed to include TalkWell in their five day training programme, which is accessed by all new staff, all bank staff and all community staff in the Trust.

Talkwell is in the process of being implemented and staff along with patients are being trained by psychology department. This is the next big initiative that we are driving and aim to have every staff member going through the work book and training.
TalkWell workshops for staff and a 6 weekly TalkWell forum Using TalkWell as part of the commissioning process for 2010/11 for Trust staff training in therapeutic communication

54

13. Star Wards as inspiration etc

Having a set project like Star Wards to work on has made it more achievable, and has allowed us to focus what we were doing, and what we needed to do. It also acted as a confident boost

For staff to know that a lot of what we were already doing was part of the star wards ideas and was on the right track! The ideas act as a reference for usto help provide reassurance, offer new suggestions and help us strive for better practice and create a supportive environment for our service users. A number of the ideas had already been talked about, e.g. A recovery file for everyone, looking at Star Wards gave us the impetus to actually do it, and again we spent time with service users discussing what the files should include. It can sometimes be an uphill struggle implementing changes on a psychiatric unit but having the star wards has really helped as it gives us something to aim for and also gives the staff and patients a good range of ideas for activities and group work.

It's good for ideas sharing and seeing how other areas have implemented good practice.

Knowing what others are doing and copying those ideas for our own wards environments. To see what has been possible on real wards and ideas for our own ward.

It is good to hear other ideas from other units and also problems that have occurred. It's nice to have a nosey at what others are doing. Gives ideas of what others are doing and we can look at what is going on that we can adapt to our unit. Definitely the swiping of ideas from other wards. Always good to have an update on success elsewhere - good to see what is achievable (and nick-able why re-invent the wheel?). Interesting to know what others are doing. Makes you feel part of something important. Variety of ideas from other areas. Newsletters placed on General Information Board for patients to see. It has always been helpful to hear what other wards are doing and what has been effective. The newsletter helps to keep the focus on Star Wards and keeps the motivation going within the team.

55

Seeing what other wards have achieved gives motivation to improve your own ward. Feeling part of the overall project. Inspirational ideas. Newsletter is a well written piece with good hints tips and supportive comments. Our journey towards achieving the 75 points of Star Wards began in 2011 officially although we were adopting the principals before this as we loved the concepts; therefore, we had already began using it as a benchmark when we made changes on the ward. We found that your ideas were simple but effective and brought about positive changes that were achievable and realistic.

We have just achieved the Full Monty award which was very satisfying for all the team. Stars wards are a very good way of ensuring that the morale on the ward is good

Your work here has been an inspiration to many! We now have a 23 bed acute ward that has no queues [for medication]. All clients are invited in to the clinical room, offered a seat, and the door shut behind them. They can then talk about their medication, what they plan to do that day, what activities are available, or whatever they want. The whole concept met with open arms and closed minds in equal measure, from both staff and clients, but it is now accepted and welcomed. I just thought I should say thanks for the encouragement. You have been and continue to be a huge influence on me and my practice, and a massive inspiration. I know so many of us feel this way. Having Marion and Buddy talking about star wards to our patients was great. Most helpful was having on site visits off Marion and Nic. This inspired us to continue with the work of Star Wards. Last year we received accreditation via the Royal College of Psychiatry, Centre for Quality Improvement in Rehabilitation and Recovery for in-patient mental Health services (AIMS). We were one of 16 sites chosen in the initial pilot scheme and one of the first in the country to receive this accreditation. Our Consultant Psychiatrist and Ward Manager were involved in the focus group that set standards nationally and remain part of the peer review system that the accreditation relies on. Why am I telling you this? Well I think we would all agree the Star Wards project went a long way to getting us on the right track to achieve this. So count yourself part of our success! We have found the whole thing really inspirational. I am not exaggerating the buzz it is causing here, it is so energising at the moment The directors commented that there has been a noticeable change on the wards as a result of Star Wards, so that says a lot!

56

Ideas that started as part of the project are now being looked at by other teams in the mental health service. I first heard of Star Wards when the unit that my husband works on began to implement their Action Plan some years ago. It was truly inspirational and restored my faith in in-patient care again. As an observer this was a fantastic piece of work that is still followed on the unit now. Our dog Lilly is an extended family member to many of the long-stay patients and is incorporated into regular walking groups. I was delighted when the opportunity arose to join the team on [our ward] and even prior to my arrival was motivated to begin work on an Action Plan. I was over-joyed when I came to [the ward] and found an action plan was already in fruition and it was a whole team approach from domestic to Clinical Nurse Manager [named], who speaks very highly of you. Since my arrival we have endeavored to implement the Action Plan and this has been marvelous for our patients, carers and the team alike. It has really brought everyone together and motivation levels on the ward have increased massively.

To conclude, it has been extremely rewarding to lead the Star Wards implementation in [our hospital]. Our hospital has been through a plethora of positive changes over the past 18 months. Clients are engaged in more meaningful activities, support staff and office-based staff are all working as one team to support our clients in all that they strive to achieve and the atmosphere on the units and in our therapy centre is that of fun and creativity. Star Wards is changing the culture of our hospital and [our hospital] has had a long, challenging yet very rewarding journey to get here. Bring on the next 18 months, for I am sure our journey has not yet ended. To end, we must say a big thank you! to Star Wards for challenging our previous practice and enriching us with so many new ideas to aid our clients recovery. We would like to invite you down to see how much [our hospital] has progressed in past few months.

14. Star Wards as a structure, and structuring Star Wards activity

When we became involved with Star Wards it was WOW. It still delivers the WOW. The website is constantly updated and its great to receive updates and to see what other wards are doing also and discuss and share these ideas. *Whats helpful is] The variety of ideas. Especially on a weekend and an evening when we are not delivering high intensity groups. And the ability to go on the star wards website and get ideas. I use Star Wards to support staff to free flow ideas not everything has to be evidenced based and that having a 1:1 with someone is an activity, having a cup of tea with someone is an activity the fact that you are spending time with service users especially in these times of austerity is important. Star Wards is used as a baseline measure for implementations on the unit. It is used as an auditing tool at times to refocus on areas that we may have become diverted from. It is patient focused and patient driven. Star Wards has had a positive impact for both patients and staff here. Through the implementation of the programme there has been increased collaborative working towards devising a therapeutic timetable of activities which compliment the variety of interests of patients at the unit. Star Wards gave us an opportunity to look at current patient care practice and make improvements where they were required.

57

Supporting staff to get the best out of their day/shift at work; using service user expertise to guide ward staff to what works for all involved. Many of the recommendations I've seen were already enacted here and seeing them as recommendations served as positive reinforcement that we were, in many ways, already on the right track. In some cases it helped sway others to changes ... such as computer access, which there was some resistance to at first. I've gone to Wardipedia on a number of occasions for ideas and find it very helpful. Thanks for putting it up. It gives us opportunities with staff and patients for discussion on how we improve the environment for the patients in our care for an enhanced stay and experience. We have used Star Wards literature as educational classes with staff at times as it gives focus and understanding on patients experiences.

The ideas act as a reference for us to help provide reassurance, offer new suggestions and help us strive for better practice and create a supportive environment for our service users. We find them helpful as a reference or guide for our service and as a way of outlining what we provide for our patients. As a health professional I find also community contacts useful within the practical ideas document as we can signpost our service users to these contacts to offer them suggestions on where they can seek further community support. We find them helpful as a reference for our service and as a way of outlining what we provide for our patients. This is also positive for when we have external visits from CCGs, PCTs and new admissions and their families as they can see the standards we meet. Star Wards gives our unit a baseline of provisions that we offer to our clients. We use Star Wards to help us improve our environment by making it as much like a home as possible and less like a hospital. The ideas star wards provide helps us to achieve our best practice with our clients through the provisions and patient driven care. Its free, all it takes is a little imagination, a bit of motivation, energy and enthusiasm. The difference it makes to the service user is immeasurable! We had a CQUIN around star wards - it really helped us to drive forward the structured activity programme It provides a structure- everythings there and you can choose to substitute activities if necessary. Star Wards has enabled us to continue with this process of continual improvement and has given us a structure to work within, enabling us to easily audit our successes, identify plans where we need to improve and most importantly capture and make use of the creativity and energy of our service users, carers and staff. Our monthly Acute Care Forum and various other groups such as the Carer Link Group and ward community meetings are used as the vehicles to listen to service user and carer needs to try to better meet the requirements of Star Wards.. Star Wards gives us the vehicle to continue to drive that constant improvement and enthusiasm for inpatient care forward.

58

More direction for staff and service users. Better structure. A more inclusive feel to the ward (especially in the evening).

It has been a good tool to demonstrate to staff and patients that a lot of what we were doing pre-SW and more of what we do post-SW is helpful and appreciated. Used as a reference in the unit. Provides a resource for our staff to look into when thinking about creative activities. Some of our achievements are a weekly comedy evening & a quiz night. We have also held a workshop for health care support workers on the ward to encourage & support them in engaging patients in activity, either groups or individually. We were doing a lot before Star Wards came along but it has really helped, not only to focus us but to implement other ideas & get the patients & carers councils more involved on a practical level We have a star wards board on the ward and we also have a standing item on the community meeting agenda. Star Wards Patient Focus Group Keen staff members have proven crucial in implementing the star wards programme - it cannot be done in isolation. Ideas have been shared between different units and once two of the units acheived the award - the competition was on and other wards have rallied to be part of star wards also. Time is a real pressure and other priorities but we have dedicated starwards meetings and etc etc and that helps but there are so many other demands nowadays for all staff etc Our main barrier in involvement with star wards is finding time in our busy days to go through the latest talk well and wardipedia updates as we work on a really busy unit with lots of different groups and activities going on and rarely find time to sit down at a computer to log on to star wards, which is why I find it easier to log on at home and forward any new ideas to my work computer ready to print off and go through at our ward community meetings. Im delighted to be part of Star Wards. The new activities are providing a structure to the patients day and good distraction (for the patients) from their illness and they really look forward to taking part. It is helping the patients to interact with one and other and with staff, so for us, even though it is early days, the difference is noticeable. A recent audit revealed that nursing staff entries into patients notes are much more informative and visitors to our ward have said that the ward atmosphere is much more settled. Each month we have had a Client led forum meeting to look at a few sections and plan actions to implement the ideas or improve on current practice. The clients wanted to start with the Recreation and Conversation section. I would advise anyone to begin with this section as it is amazing what excellent practice is already going on that we are unaware of. We ensure that at

59

all times clients are leading us forward in our progression at [our hospital] and that they remain firmly at the centre of all decisions made.

[Star Wards] provided a forum in which the team could reflect on how we are delivering care, how effective this is and whether we are delivering it to our full potential and highest standards. Whilst most ideas are current practice, the process of going through each individual idea has given us the opportunity to reflect on ways of improving our current practice. It has also given patients the opportunity to feel more involved and take responsibility for the development of their service and their own personal experience during admission. By encouraging a service user perspective in the process we have been able to reflect on how we communicate to patients about the services and opportunities we are offering and consider whether we are doing this in an effective manner for service users. It was when we held the first Client Star Ward forum meeting that things began to click in place. It was evident that *our hospital+ had already achieved so much that we hadnt even recognised before looking at the Star Wards ideas chart. This gave us all a massive push to continue with the fantastic things already in place and to begin to tweak, improve and create a batch of fabulous new ideas. The Star Wards Steering Group was founded in February 2008 - a time when the service was going through major reorganisation. As a result of all the changes, at first the progress of Star Wards initiative was slow but it has steadily gathered pace. There is now a Star Wards champion on each ward and baseline audits have been completed leading to a shared action plan which is regularly reviewed. The Star Wards group also has service user and carer members who provide invaluable insights and expertise as to how the inpatient experience can be improved. In September 2008, Marion Janner, the Founder of Star Wards, visited and met with staff, service users and carers to see the major environmental improvements and to inspire us to continue to improve and make inpatient care more enjoyable for everyone involved. Staff have responded positively to Star Wards as they have started to realise since Marions visit that it is not just about doing the 75 ideas set out in the original handbook it is about far more, in particular harnessing their own and service users energy and ideas and shouting about the good things they already do. Star Wards gives us the vehicle to continue to drive that constant improvement and enthusiasm for inpatient care forward. It's nice to find out what's happening across the Star Wards 'family'. I have just heard that you have totally revolutionised [our] hospital's ward, from a psychologist who works there, and that it is now the rules that the ward has to meet all of Starwards recommendations! And that your impact is just huge. And that they are making a place for pets! HUGE CONGRATULATIONS! I have been meaning to get in touch with you for a while to tell you about how you've inspired [the leader of the European mental health e-learning] project to develop some written guidelines for how to care for distressed and disturbed inpatients for use in *a European nations+ hospitals. This is a really positive step as up until now there have been no such formalised guidelines in place over there. She told me she was

60

very struck by your input at the meeting last year and was inspired to take some direct action that will hopefully make a real difference to the inpatient experience. As a unit, we use Star Wards to ensure that patients are involved in several aspects of their care.

Wardipedia is really useful and we are hoping to implement Ward Buddy on the unit soon.

Star wards is making us look at the hospital service and environment holistically and allowing us to focus on areas for improvement we had not considered before.

The ideas star wards provide helps us to achieve our best practice with our clients through the provisions and patient driven care.

Star Wards gives us an insight into what clients want in their environment. It helps us to look at the environment from a fresh perspective and better understand and appreciate our clients needs. It also brought to our attention elements that may have not been considered, for example the spiritual needs of a client can often get overlooked as well as encouraging clients to have their say in how the hospital is run.

Through the implementation of the programme there has been increased collaborative working towards devising a therapeutic timetable of activities which compliment the variety of interests of patients at the unit. Star Wards gave us an opportunity to look at current patient care practice and make improvements where they were required.

Star Wards provides a beacon of practical good practice for staff who want to improve service user experience on their wards. Its adoption is one of the things which helps distinguish good wards.

Far and away the greatest impact has been the recommendation of having up to 4 hours of peer volunteer time per day. This one recommendation has been transformative.

Star wards plays a big part in the way we deliver our activities. Ive made it the role of the nursing assistants to use Star Wards to their advantage to enrich the activities we deliver. Star Wards supports the work we do as I quote Marion all the time in explaining the need to prove activities and have protected time to deliver them, I recently used Star Wards in a presentation I did to our membership board as a way of evidencing the activities we deliver.

I use Star Wards to support staff to free flow ideas. Having a set project like Star Wards to work on has made it more achievable, and has allowed us to focus what we were doing, and what we needed to do. It also acted as a confident boost for staff to know that a lot of what we were already doing was part of the star wards ideas and was on the right track!

61

15. Sustainability in UK and overseas

Although our specific 'star wards' group has fallen apart (we tried to meet regularly and implement ideas from star wards but other commitments slowly took over), we have still managed to use heaps of ideas, continue to consult and be inspired by the resources. Perhaps we are not officially involved... but we use the resources. Star Wards has helped us to further improve the experience of being an in-patient in [our Trust]. It has given us a framework for both leisure and therapeutic activities which are valued by service users and staff alike and is a growing force for channelling the enthusiasm and ideas of service users, frontline staff and carers. Through Star Wards, we have been able to recognise what we already do well; we dont do so well, and, what we could start doing again or for the first time. It also allows cross-fertilisation and adaptation of ideas and initiatives across older peoples wards, adult wards and the PICU. We aim to work on those aspects of Star Wards that need further development and to keep up our performance on all the rest. I use [newsletters] when emailing students as a way of making sure they know about developments, but also as a way of socialising them to the idea that they need to stay up to date / develop / be open to new ideas. Just keep doing what you are doing. Clone Marion and Buddy so we can have them full time in every ward!

We received the Star Ward status in 2008 and we have continued to maintain these ideas. Star wards is something we also regularly discuss in OT meetings to ensure we are maintaining the ideas.

Over the last two years since gaining the Full Monty Award we have strived to keep these ideals as part of the unit. We also display these ideals and our award on the unit and use these as a reference for internal audits and patient surveys.

Star Wards impact remains much the same. Wardipedia is really useful and we are hoping to implement Ward Buddy on the unit soon.

The impact still continues as it has from the start but also has improved with new ideas and activitys that has been going on Eg: New equipment for our Gym, More inhouse and outhouse activitys etc.

Just to continue with the star wards as it is enjoyed by all.

62

We find the online publications, guidance and updates extremely useful, which in turn helps us to continue to be up to date. The new ward buddy scheme has also been an important factor in the implementation of the *name of hospital+ patient guide for new patients admitted to the unit. [Our] Director of Development, said this training is demonstrating how TalkWell is becoming part of mainstream practice on the wards, with positive impacts being seen on communication between patients and staff, and also within staff teams. Star Wards continues to be at the forefront of our considerations when developing new activities and opportunities

Star Wards still carries the same impact as it always has. The new initiatives such as Wardipedia have helped to keep the idea and concept of star wards fresh and modern.

I dont think that the wards at [the hospital] are involved with Star Wards at all which in my view & from my previous experience as a Consultant Nurse in Inpatient Care - is a great shame. I will contact one of our Consultant Psychologists who has a remit focused on inpatient care to check thats so and suggest a gentle push in the direction towards Star Wards.

The impact has not changed over the last two years. As a lead reviewer for the AIMS project with the Royal College of Psychiatrists I actively encourage other wards to use Star Wards particularly selling it to nursing assistants.

Unfortunately we do not have a strong star wards focus now as we did in the past as we had to rationalise the number of initiatives we were focusing on, and it was decided that releasing time to care took priority (although Star Wards would complement releasing time to care). Our main achievement was the development of volunteers in the wards and with OT services, which is still going strong. We appreciate the star wards updates and newsletters however. I am in a Community Health Unit in Australia and use the resources because they are excellent.

To round off our impact review, it feels worth including again what the Kemp research said about our sustainability, as the ultimate for us is to have our approach and resources fully integrated into all wards everyday life:

Structures and processes have been embedded in NELFT practice and will be extended to all inpatient facilities in the trust. Responsibility for the project practices has been transferred from the Star Wards and Productive Ward leads to modern matrons, and its outcomes have been incorporated into the trusts performance framework. In other words, the developments have become business as usual

63