1. Low secure service for Scottish women The Ayr Clinic Clinical Forum: Women in Forensic Mental Health Setting 07.02.2014 Pradeep Pasupuleti, Laura Stevenson and Emma Hargreaves Partnerships in care

2. Todays talk Introduction Service at the Ayr Clinic Our Experience Future plans The Ayr Clinic, Partnerships in Care 2

3. The Ayr Clinic 2008 34 beds 2 admission wards and 1 rehab ward Low secure service 3 The Ayr Clinic, Partnerships in Care

4. 4

5. Female service Admission ward and mixed-sex rehab ward MDT model 2008-2013 Total admissions - 95 Total female admissions- 27 Discharges- 14 Longest admission- 4 years 7 months Shortest- 1 month 5 The Ayr Clinic, Partnerships in Care

6. Arran ward 6 The Ayr Clinic, Partnerships in Care

7. Patient profile Story of Miss S- 25 years old, inpatient since the age of 15, transferred from IPCU, prolific self harmer specifically inserter, vague psychotic symptoms Story of Miss A- 21 years old, in care since the age of 9, prison transfer, serious offender, violence as primary defense, self harm behaviour, psychotic episode Story of Ms M- 46 year old, schizophrenia, violence towards family members, transfer from a local open ward, unsuccessful community rehabilitation 7 The Ayr Clinic, Partnerships in Care

8. Challenges- Patient related Patient mix Hybrid nature of needs Complex personality disorder, Dual diagnosis, primary MI Extreme levels of self harm Problems in forming and maintaining relations 8 The Ayr Clinic, Partnerships in Care

9. Challenges- security related Forensic v low secure Paradoxical effect Enhanced relational security Physical security Risk management v recovery A missing step into community 9 The Ayr Clinic, Partnerships in Care

10. Challenges- Staff related Recruitment Staffing Confidence and morale Higher observations v Therapeutic relationships Training Sickness Supervision 10 The Ayr Clinic, Partnerships in Care

11. One size doesnt fit all! Patient-involved v Patient-centered model Physical environment Tailored procedural security Zonal and modified zonal observations Well supported relational security – fora, RP, supervision, training Ward programme 11 The Ayr Clinic, Partnerships in Care

12. An average day on Arran A semi-structured model Morning briefing meeting Rehabilitation v Recreation, striking a right balance Low intensity/and open skills-based groups v Higher intensity groups and 1:1 work Mindfulness, Relaxation, Social skills/communication group, Managing Emotions DBT skills group and 1 to 1, Anger Management, Anxiety Management, Coping with mental illness, D&A programmes 12 The Ayr Clinic, Partnerships in Care

13. Ward Bingo! 13 The Ayr Clinic, Partnerships in Care

14. Feedback Improved ward dynamics experience of safety by patients using EssenCES questionnaire (Essen Climate Evaluation Schema) Improved attendance at patient fora Reduction in the number of incidents Reduction in observations 14 The Ayr Clinic, Partnerships in Care

15. Pre Christmas celebrations 15

16. Relationships group Underlying patient conflicts / dynamicsUnrecognised ward tensions & incidentsExplicit discussion in an informal group settingEnables clarification and experience of more functional relatingEnables nursing staff involvement & experience of working 16 The Ayr Clinic, Partnerships in Care

17. Future Sustainability factor Co-production models My shared pathway My risk management Vocational education and training Real work opportunities Strong focus on physical health Development of broad based Mentalisation Model 17 The Ayr Clinic, Partnerships in Care