Hafan Wen Statement of Purpose

(1)

CYNGOR ALCOHOL INFORMATION SERVICE

Hafan Wen

Statement of Purpose

(2)

Page

|

1

Table of Contents

Page Number

1.0

Section One: Introduction

4

1.1

Overview of the organisation and Service

5

1.2

Contact Details

7

1.3

Aims and Objectives

9

2.0

Section Two: Organisational Structure and Staffing

10

2.1

CAIS Organisational Structure

11

2.2

Hafan Wen Organisational Structure

12

2.3

Staffing and Qualifications

13

2.4

Staff Recruitment

18

2.5

Continuous Professional Development

19

2.6

Training

20

2.7

Supervision

21

3.0

Section Three: Service Provision

22

3.1

Accommodation and Facilities

23

3.2

Treatment Provision

24

3.3

Detoxification from Alcohol

25

3.4

Detoxification from Opiates

28

3.5

Detoxification using Methadone

29

3.6

Detoxification using Lofexidine

31

3.7

Detoxification using Subutex (Buprenorphine)

33

3.8

Detoxification from Stimulant Drugs

34

3.9

Benzodiazepines

36

(3)

Page

|

2

Table of Contents cont.

3.11

Relapse Prevention

38

3.12

Therapeutic Programme

41

3.13

Referral

42

3.14

Assessment

43

3.15

Pre Admission

44

3.16

Admission and Eligibility

45

3.17

Discharge

46

3.18

Aftercare

47

3.19

Service User Involvement

47

3.20

Ex Service User Involvement

48

4.0

Section Four: Quality Assurance

49

4.1

Quality Improvement Model

50

4.2

Clinical Governance

51

4.3

Complaints Procedure

53

4.4

Incident Reporting

55

4.5

Responding to Emergencies

56

4.6

Reporting and Monitoring

57

5.0

Section Five: Values Statement

58

5.1

Privacy and Dignity

59

5.2

Equality and Diversity

60

5.3

Confidentiality

61

5.4

Risk Assessment

62

5.5

Risk Management

62

(4)

Page

|

3

SECTION ONE

(5)

Page

|

4

Introduction

This document sets out the Statement of Purpose for Hafan Wen Substance Misuse treatment Clinic.

The Hafan Wen statement of purpose provides a range of information which is intended for a wide audience including:

Betsi Cadwaladr University Health Board Healthcare Inspectorate Wales

Local Authorities and Primary Care Trusts Commissioners

Colleagues within other organisations providing similar services Service Users

General Public

It will be made available electronically on the internet at the CAIS and Hafan Wen website to enable wide audience access

This Statement of Purpose aims to meet requirements in-line with all relevant legislation, outlining how we will fulfil our range of duties and responsibilities in meeting the needs of the people and communities we serve.

The Statement of Purpose will be reviewed and updated by the CAIS Board of Governors and Registered managers of the clinic to ensure accuracy is reasonably maintained.

(6)

Page

|

5

Overview of the Organisation and Service

CAIS

CAIS (Cyngor Alcohol Information Service Limited) was incorporated in 1992 and registered as a charity in 2004, although it has been delivering substance misuse services since 1976. CAIS is one of the leading providers of drug and alcohol services in Wales, whilst providing residential detoxification and rehabilitation services to clients in both England and Wales.

Hafan Wen

Since 1997 CAIS has delivered a medically managed, service user focused residential detoxification service throughout North Wales on behalf of the Betsi Cadwaladr University Health Board and has established additional agreements with three other Health Trusts. Staff were originally transferred to the clinic from the North Wales Psychiatric Hospital in Denbigh which ensured retention of expertise as the basis for continuous improvement.

The service is provided at CAIS’ residential clinic in Wrexham called Hafan Wen, which provides drug and alcohol detoxification and treatment programmes that take into account the needs of males and females aged 18 years and over. Based on the client’s level of substance misuse dependency we demonstrate flexibility in our ability to provide packages of care, typically from 3 – 28 days and more where deemed appropriate based on assessment and identified need.

The treatment programme is person-centred and adopts a holistic approach including having regard to mental and physical health, social, personal, nutritional and cultural needs. The service user is involved in all aspects of care from pre admission assessment through to aftercare as part of an ongoing Integrated Care Pathway (ICP) process. The pre and post elements of treatment are delivered by the referring Community Drug and Alcohol Service whilst Hafan Wen provides the residential detoxification and treatment element of the service.

Service users are involved in all aspects of their care at Hafan Wen and we believe that achievement of agreed goals is dependent on a high level of collaboration and choice, applied at the most appropriate time for the user.

(7)

Page

|

6

Hafan Wen ensures continuous quality improvement by utilising feedback from its Stakeholder, Service User and Clinical Governance Groups and actions annual recommendations and requirements made by the Health Inspectorate Wales.

The Clinic provides a medically managed drug and alcohol detoxification and treatment programme, led by a consultant psychiatrist and supervised 24/7 by qualified nursing staff. The broad range of staff competencies within the clinic and throughout CAIS ensures quality care, delivered by experienced and knowledgeable professionals.

(8)

Page

|

7

Contact Details

Name and Address of the Registered Provider:

Registered Provider:

Hafan Wen - Hafan Wen is registered with the Health

Inspectorate Wales

Registration No:

Address:

Hafan Wen Treatment Clinic

Watery Road

Wrexham

LL13 7NQ

Telephone:

01978 313904

Registered Managers:

Hafan Wen Manager: Elizabeth Jones

Email: [email protected]

Telephone: 01978 313904

CAIS Tier 4 Services Manager: Geraint Jones

Email: [email protected]

Mobile: 07767 408036

(9)

Page

|

8

Location Map

Hafan Wen Treatment Clinic

Watery Road Wrexham LL13 7NQ

Hafan Wen Treatment Clinic

Watery Road Wrexham LL13 7NQ

(10)

Page

|

9

Aims and Objectives of the Service

Hafan Wen aims to provide a flexible range of treatment options to help people achieve abstinence or stabilisation from drugs and alcohol whilst developing the skills and knowledge of service users to develop and maintain a healthy lifestyle balance.

Hafan Wen Core Purpose and Goals:

Hafan Wen aims to help people affected by drugs and alcohol throughout the UK by providing them with a range of timely and flexible treatment interventions in a safe and empathic environment whilst enabling and empowering them to make significant lifestyle changes.

To provide access and choice to people who need residential treatment to address their substance misuse problems. That people regard us as the first choice substance misuse treatment facility to work with and for.

Our communities will be involved, informed and empowered in the development and continuous improvement of the clinic.

The first choice provider of services delivered by a workforce known for excellence.

Safe and Quality focussed service.

Promoting health and empowering people to change. Excellence in business planning, process implementation and marketing of services.

Consistently fit for purpose.

Collaborative working with a wide range of stakeholders.

We will treat all stakeholders with respect and acknowledge their knowledge and expertise.

We will make a positive contribution to all we do by having a positive attitude, ensuring all we do adds value to the users experience and to achieve positive outcomes.

We will treat our clients with dignity and demonstrate the highest levels of empathy.

We will value and develop each other, supporting professional development, maintaining and improving standards recognising individual and collective skills, knowledge and achievements.

We will have a holistic approach to assessment treating all with respect and valuing individual opinions

We will have an ethical approach treating all as we would wish to be treated ourselves.

Collectively and personally committed to:

The best interests of the whole and caring for the individual. Utilising resources intelligently to deliver excellent outcomes and attract further investment. Inspired by innovation and committed to maintaining and improving core activities Purposeful partnerships. Continuous Quality Improvement

Our Principles

Our Stra

tegic

Goal

s

Our Stra

tegie

s

Our Val

ues

(11)

SECTION TWO

ORGANISATIONAL

STRUCTURE &

(12)

(13)

(14)

CAIS’ Tier 4 Services Manager is identified as the Responsible Individual for Hafan Wen and is registered with the Healthcare Inspectorate Wales. The Tier 4 Services Manager line manages the Clinic Manager and takes a lead on the strategic development of Hafan Wen.

Nursing Staff Complement and Qualifications

Name Title Qualifications Experience Elizabeth Jones Clinic Manager RNMH, BN

Independent Nurse Prescriber Life Coach, Dip.

ILM Certificate –Management

12 years

Drug/Alcohol Service

G. Jones CAIS Tier 4 Services Manager

RMN,

MSC Health Education

24 years

Drug/Alcohol Service D.B. Staff Nurse RMN, RGN 31 years

Drug/Alcohol Service T.M.F Staff Nurse RMN

OCR Level II Gym Instruction (Vocational Certificate)

20 years

Drug/Alcohol Service D.F-G Staff Nurse RNMH

BSc Psychology

Foundation Degree Substance Misuse

Counselling Certificate

9 years

L.G. RMN BA (Hons) Social Sciences

BN (Hons) Mental Health Nursing

2 years

Drug/Alcohol Service A.S. Staff Nurse RMN 40 years Psychiatry and

Drug/Alcohol Service P.J-H Staff Nurse RMN 30 years Nursing

B.B. HCSW NVQ2 25 years

Drug/Alcohol Service P.B. HCSW Working to NVQ 3

Urine Analysis training from Siemens

8 years in Acute Psychiatry 7 years Drug/Alcohol Service V.G. HCSW NVQ3 13 years Drug/Alcohol Service K.H. HCSW Working to NVQ 3 13 years Acute Psychiatry

4 years

(15)

Page

|

14

Nursing Staff Complement and Qualifications cont.

P.H. HCSW BSC (Social Science)

Dip. App. Social Science Dip Mental Health Nursing, Cert Counselling

Cert Health & Social Care Cert Group Work

4 Years drug and Alcohol Service M.J. HCSW 14 years Drug/Alcohol Service S.P. Group/Activities Co-ordinator Working to NVQ 3

Group Work Qualification Basic Counselling

4 years

S.P. HCSW NVQ3 12 years

Drug/Alcohol Service C.R. HCSW Substance Misuse Course 7 years

L.W. HCSW NVQ2 20 years

Drug/Alcohol Service A. H. Admin/Reception OCR Level 2 (CLAIT Plus)/Text

Production/Typewriting/Shorthand AMSPAR Diploma NVQ II Customer Service BSL Introduction 8 years Drug/Alcohol Service S. E Art/Tutor BA Hons

PGCE – Post Graduate Cert Education

9 years

Drug/Alcohol Service S.W. Catering Manager L2 NVQ Catering & Hospitality

L3 NVQ Catering Management A1 NVQ Catering & Hospitality Accessor Award

BTEC Intermediate Award I.T., Communication, Maths Intermediate Food Safety Food Hygiene

A.S. RNMH BN (Hons) Mental Health Nursing 2009

Moving & Handling

Harm Reduction & Needle Exchange Tissue Viability Link Nurse from Sept 09 – June 2011

Domestic Abuse in Pregnancy Tissue Viability & Wound Dressing Selection Work

(16)

Page

|

15

Staffing levels based upon client occupancy

Staffing Based Upon 15

bed occupancy HOURS STAFF NUMBERS STAFF MIX

Monday-Friday 7.30am-5.45pm 4 2 Qualified Nurses

2 HC Support Workers

8am-4pm 1 1 therapeutic Co-ord

10am-5pm 1 1 I.T./Art Tutor

5pm-5.45pm 4 2 Qualified Nurses

5.45pm-8pm 3 1 Qualified Nurse

2 HC Support Worker

Saturday-Sunday 7.30am-5.45pm 4 2 Qualified Nurses

2 HC Support Worker

Nights 7.55pm-7.35am 3 1 Qualified Nurse

2 HC Support Worker Staffing Based Upon

15-20 bed occupancy HOURS STAFF NUMBERS STAFF MIX

8am-4pm 1 1 therapeutic Co-ord

1 HC Support Worker

2 HC Support Worker

2 HC Support Worker Staffing Based Upon

20-25 bed occupancy HOURS STAFF NUMBERS STAFF MIX

8am-4pm 1 1 Therapeutic Co-ord

2 HC Support Worker

1 HC Support Worker

(17)

Page

|

16

Nursing Staff

To ensure nurses and allied health professionals and other professionals, have and maintain current and appropriate registration with the relevant UK professional and regulatory bodies CAIS has robust systems in situ:

Details of registration with appropriate professional and regulatory bodies are checked with relevant body prior to appointment and details of registration are maintained on staff Personnel Files.

Details of NMC registration are checked annually to demonstrate good practice and as part of the requirements of the Health Inspectorate Wales.

Continuous Professional Training and Development is provided to ensure staff gain relevant qualifications i.e. NVQ level 4.

All staff are DANOS (Drug and Alcohol National Occupational Standards) competent and are appraised annually to confirm their continued levels of competency.

All staff have been trained in evidence based recovery techniques, namely the ITEP (International Treatment Effectiveness Programme). Also CAIS provides opportunities for staff to develop their knowledge by offering placements on a Substance Misuse Foundation Degree developed by CAIS and the School of Lifelong Learning at Bangor University.

(18)

Page

|

17

Medical Staff

Clinical processes are led by the Consultant Psychiatrist who is employed and managed by the Betsi Cadwaladr University Health Board. The consultant provides expert diagnosis and leads on all aspects of the clinical detoxification of all residents at the clinic. Consultant supervision is provided by peers working within the Health Board which ensures consistency and best practice based on the most up to date prescribing protocols.

Links with the Health Board assures CAIS that the consultant works within his remit and that practice is based on validated protocols. Integrated networking also ensures a consistent approach to developments within the general medicine, psychiatry and substance misuse disciplines.

The consultant provides leadership to junior doctors and advises the Clinic Nurse Manager as to research evidence that promotes the clinical effectiveness of Hafan Wen. As part of this role the consultant sits on the Hafan Wen stakeholder group and takes a lead role in the clinic’s Clinical Governance meetings.

(19)

Page

|

18

Staff Recruitment

CAIS’ recruitment, selection and retention policies satisfy good workforce practice and satisfy the regulations and standards as set out by its regulatory bodies and the Investors in People standards. In relation to recruitment and selection CAIS has;

A Recruitment and Selection Policy. This policy incorporates a structured Recruitment Checklist and includes the utilisation of CRB enhanced disclosures as appropriate.

A Recruitment of Persons with Criminal Record Policy. Equality and Diversity Policy incorporating an Action Plan.

In relation to retention and good practice CAIS has:

A Continuous Professional Development process in place consisting of structured induction, annual performance review and structured incremental pay scales.

Provision of regular management and clinical supervision.

A Human Resources Sub Group forum to carry out policy reviews and to discuss and share good practice.

A Staff Association forum to consult on and discuss all aspects of the business and its operations. Investors In People status (currently operating beyond base standard)

Qualified staff in place to monitor and address all aspects of Health and Safety

These and other policies are used to provide guidance on best practice for those involved in processes and those policies are reviewed regularly and updated to reflect employment legislation requirements, and good practice.

(20)

Page

|

19

Continuous Professional Development

In terms of Continuing Professional Development CAIS offers an annual appraisal process coupled with a 6 monthly monitoring review meeting with each member of staff to identify and agree development needs which are then enshrined within the Company’s training plans and priorities. Part of the Staff Appraisal process has also been developed to monitor objectives related to competencies attached with each job role and staff, are encouraged to develop a file of evidence to demonstrate compliance with and examples of competencies demonstrated during the year.

CAIS is also a rare example of offering clinical supervision as well as management supervision to all the staff. Management supervision centres around personal and performance issues since many of the job roles are closely linked to contractual and qualitative requirements. Clinical Supervision centres around the maintenance and development of best practice.

Clinical Supervision sessions contain 3 main functions, namely:

1. Educative or formative: to do with developing knowledge, skills and understanding of workers usually by focussing on casework

2. Supportive or restorative: support of workers who are exposed to the distress and pain of clients; by providing time for them to become aware of how this has affected them and to deal with any reactions (discharge and recharge batteries)

3. Managerial or normative: the aspect of supervision which is concerned to ensure a satisfactory standard is maintained in relation to practise

Our insistence on recruiting and supporting the best available staff who share CAIS’ Mission, Vision and Values in this way underpins the promotion of best clinical practice in support of service users within a safe and high quality environment provides an effective framework for optimal, personal outcomes.

(21)

Page

|

20

Training

Hafan Wen provides mandatory Clinical supervision to its qualified and non-registerable healthcare staff and all must attend the CAIS core training provided by the organisation. Additional training needs and compliance to DANOS standards are identified during annual appraisal.

Our commitment to the Investors in People reinforces our developmental responsibilities to staff and the organisation is assessed every 2-3 years or more regularly if we request.

All Hafan Wen staff receive an annual appraisal from which a personal development plan is agreed. Mandatory training is prioritised as compulsory and other training needs are met through internal and external support mechanisms.

Mandatory Clinical Training requirements are identified through the Tier 4 Services Manager, CAIS Directorate and Clinic Manager in collaboration with the training department based on the DANOS Competencies and NMC registration requirements. This ensures continuous Professional Development and promotes relevant levels of expertise to meet the requirements for each role and grade.

CAIS has a dedicated training department that delivers training programmes to ensure that all staff undertake relevant clinical/non clinical training. A selection is illustrated below:

Mandatory Non Clinical Training

CAIS and Hafan Wen Induction Community Services

Manual handling Fire Safety First Aid Data Protection Health & Safety Equality & Diversity Child Protection

Protection of Vulnerable Adults Incident Reporting

Disability Discrimination Awareness Personal Safety

Clinical Training

Clinical staff undertake the range of clinical training relevant to their profession / areas of service delivery.

CAIS Training department offers a range of training options for the clinician and additional identified training is accessed externally where the need is identified. CAIS Clinical Training Includes:

Motivational Interviewing Counselling skills

Introduction to Groupwork Relapse Prevention

Peer Mentoring Skills (listening, communication, client boundaries etc) Dual Diagnosis

(22)

Page

|

21

Supervision

Hafan Wen provides clinical and management supervision to all staff.

Hafan Wen management supervision addresses personal and performance issues since many of the job roles are closely linked to contractual and qualitative requirements.

Clinical Supervision addresses the maintenance and development of best practice.

Clinical Supervision sessions undertaken at Hafan Wen contain 3 main functions, namely:

1. Educative or formative: to do with developing knowledge, skills and understanding of workers by focussing on caseloads and reflective practice.

2. Supportive or restorative: support of workers who are exposed to the distress and pain of clients; by providing time for them to become aware of how this has affected them and to deal with any reactions. 3. Managerial or normative: the aspect of supervision which is concerned to ensure a satisfactory

(23)

Page

|

22

SECTION THREE

(24)

Page

|

23

Accommodation and Facilities

Hafan Wen acknowledges the need for privacy and safety for clients especially at such a difficult and vulnerable time. Whilst residents are supervised in all aspects of activities and therapies they are afforded a high level of privacy and respect in a clean, conducive and safe environment.

Accommodation

25 Single en-suite bedrooms

4 Lounges (one of which is designated for females only) Bathroom

Disabled Access Showers

Facilities

Kitchen

Kitchenettes in all 4 lounges Laundry Relaxation Room Art/Computers Room Recreation Room Groupwork Room Counseling Room Aerobic Gymnasium

(25)

Page

|

24

Treatment Provision

Treatment Programmes

The clinic offers flexible treatment packages that include stabilisation and detoxification and are individually tailored to meet the needs of service users. In addition to standard detoxification and stabilisation regimes offered at the clinic additional treatment options are also available. Examples include:

Short residential detoxification for alcohol of no less than five nights that can be completed in the community by the Tier 3 services.

Completion of the last few difficult days of a drug detoxification in a safe supervised setting.

A four week treatment package that includes detoxification and respite in preparation for residential rehabilitation. Although this is uncommon it is sometimes necessary due to their poor state of health on admission. It also provides more time in therapeutic engagement and discharge planning especially where the needs are complex.

This flexibility of approach demonstrates our desire to ensure service users get the services they need when they need them. In summary Hafan Wen “works around” the needs of the service user where practicable and appropriate and this is possible due to the close collaboration with the statutory referring agencies. We understand that service users have varied needs and acknowledge our responsibility within the Integrated Care Pathway approach to facilitate continuity of care throughout their treatment at Hafan Wen.

These close links with the Betsi Cadwaladr University Health Board are also beneficial when service users need more specialist care in the event of an acute psychiatric or medical emergency. Although rarely used the close proximity of the Board’s psychiatric and medical facilities on the Wrexham Maelor Hospital site and agreed protocols ensures efficient and seamless transfers when necessary.

Inclusivity is core to CAIS’ and Hafan Wen’s philosophy of care and where appropriate every effort is made to accommodate the varied and often complex needs of all service users. Where risk is identified the unit manager will initiate a three way meeting with the service user and their worker to assess for suitability and develop contingency plans for potential problems. Service users with challenging behaviours and histories of violence and high risk behaviours are assessed on an individual basis.

(26)

Page

|

25

Detoxification from Alcohol

The majority of patients can be detoxified safely in the community following the agreed BCUHB guidelines. Inpatient treatment is indicated where there is:

History of withdrawal fits and/or delirium tremens Current, severe polydrug use in addition to alcohol

Psychiatric co-morbidity that increases risk to self or others

Poor physical health e.g. diabetes, liver disease, hypertension, malnutrition Lack of appropriate home support or suitable accommodation

History of failed community detoxification over last 12 months

There is no routine medical cover at weekends. Patients with alcohol problems should not be admitted on a Friday, to ensure that there is maximum medical supervision for the early and most risky period of withdrawal. This applies unless the admission plan is agreed by senior staff.

Process

1. History, physical examination, review/repeat FBC U&E LFT Gamma GT INR.

2. Time of most recent drink and breath alcohol concentration(BRAC); (NB: The body can metabolise approx 1 unit/hour hence the BRAC falls by 10-20 mg/dl per hour)

3. Chlordiazepoxide is the drug of first choice. Benzodiazepines exhibit cross-tolerance with alcohol, are anxiolytic, sedative, anticonvulsant and have a high safety to toxicity ratio. If liver function is severely compromised Oxazepam may be used on advice of senior staff.

4. Patients who are prescribed benzodiazepines for dependency will have this stopped and in line with NICE guidance. The withdrawal should utilise one benzodiazepine rather than two or more. (see guidance on patients with severe mental illness for exceptions to this)

5. The dose of Chlordiazepoxide required will vary. Withdrawal symptoms usually commence within 4-12 hours after the last drink when blood concentration of alcohol has sharply declined.

(27)

Page

|

26

6. Before any medication is administered staff should undertake the CIWA-AR (appendix). The dose prescribed in the first 24-48 hours will be flexibly determined against the CIWA-AR scale. Chlordiazepoxide should not be commenced if the patient is intoxicated with alcohol, or sedated with any depressant drug.

7. The maximum dose of Chlordiazepoxide should be 200 mg in a twenty four hour period. If a patient is still experiencing significant withdrawal on this dose, as evidenced by CIWA-AR staff should consult senior medical staff for advice and review.

8. Before any medication is administered nursing staff should undertake the CIWA-AR. For the first 48 hours nursing staff should complete the CIWA-AR four times a day; alongside 4 hourly observations of temperature, respirations, and blood pressure. The amount of Chlordiazepoxide prescribed will depend on the rated CIWA-AR score in the first 24 hours and should avoid both under treatment and over medication (there is a risk of excessive sedation and possible interaction with alcohol recently consumed pre-admission). For some patients with severe dependency it may take 48 hours to achieve control of withdrawal symptoms. Most individuals should be off all benzodiazepines within 7 days although a minority of severely dependent patients may require up to 10 days.

CIWA-AR Score Severity of withdrawal Dose range of

Chlordiazepoxide (mg)

< 10 Mild 0

10-20 Moderate 20-30

20+ Severe 40

8 The prescriber will specify the maximum dose each day allowing for PRN if indicated by the CIWA-AR score. After the first 24–48 hours no PRN should be required and a reduction regime is commenced at approximately 20% less Chlordiazepoxide each day, aiming at reducing off within seven days. Chlordiazepoxide is prescribed QDS on the basis of the CIWA-AR.

9 Where patients have a clear history of recent alcohol withdrawal convulsions during previous detoxifications, give Carbamazepine 200mg bd, tapering off in week two. Patients should not be discharged on this medication. N.B. Patients who are being treated for epilepsy should have their usual anticonvulsant medication prescribed.

(28)

Page

|

27

12. Dehydration can occur during alcohol detoxification and nursing staff must ensure adequate fluid intake. Commencement of a fluid intake chart may be useful and should be implemented if patients are observed to be not drinking, in these circumstances staff should oversee intake and monitor patients carefully until a light diet and normal fluid intake is tolerated.

Vitamins

All patients undergoing alcohol detoxification who score as severely dependent on the CIWA-AR, patients with less severe dependency with a BMI less than 18, patients suffering from peripheral neuropathy and those with any suspicion of Wernicke’s encephalopathy (confusional state, opthalmoplegia & ataxia), Korsakoff’s psychosis or other alcohol-related neurological condition, should be commenced on a course of intramuscular vitamins (Pabrinex), 1&2 amps, daily for 3-5 days by deep intramuscular injection. This will be followed by oral Thiamine 100mg bd.

All other patients should receive oral thiamine 100mg bd. Other vitamins may be required based on the clinical judgement of the inpatient medical team.

The therapeutic treatment for presumed/diagnosed Wernicke’s encephalopathy and delirium tremens requires transfer to a general medical setting. Contact Medical Registrar for advice, or if there is delay, transfer to A&E.

(29)

Page

|

28

Detoxification from Opiates

1. Withdrawal from opiates can be unpleasant but it is not life threatening, whilst opiate toxicity is potentially fatal. All patients completing detoxification must be warned that their tolerance to opiates is likely to have reduced and that they are at increased risk of accidental opiate (and poly-drug) overdose.

2. No injectable preparations will be prescribed during inpatient detoxification and patients will be transferred to an agreed oral preparation. The oral preparation agreed and dosage should be discussed with the relevant community Consultant and inpatient medical team prior to admission.

3. Patients who are poly-substance dependant prior to opiate detoxification should complete an alcohol/benzodiazepine detoxification before they commence their opiate detoxification. This may require a longer admission period or more than one admission to achieve drug free status.

4. Consideration should be given to current Hepatitis B vaccination status and the inpatient opportunity utilised to address any due boosters or to commence vaccination if not previously received. Whilst discussion should take place around blood-borne virus risk factors, screening while undertaking a detoxification may not be suitable for some patients and the decision to routinely screen at this stage needs careful consideration.

Symptomatic Treatment

Any patient withdrawing from opiates may benefit from symptomatic relief of the following symptoms with the following non-opiate drugs:

Abdominal cramps: Mebeverine 135mg tds

Diarrhoea: Loperamide 4mg initially then 2mg with each loose stool Muscle and joint pain: Paracetamol or NSAIDS

Anxiety and agitation: Promazine 25 mg tds prn (maximum 200mg/day)

Quetiapine 25-50mg tds (second line)

Night muscle cramps: Quinine sulphate 200mg nocte (should not be needed at the start of detoxification).

These preparations should be prescribed in the “as required” section of the drug sheet in accordance with current BNF and product specification.

(30)

Page

|

29

Detoxification using Methadone

The proposed length of stay and proposed treatment regime should be agreed prior to admission and should enable the patient to realistically achieve their admission goals. It is imperative that current dose details and information of last dose administered are given to the inpatient staff by the keyworker prior to admission.

Process

1. On admission nursing staff will check current dose of any prescribed medication with keyworker or community pharmacy. Ascertain from patient whether the full dose has been taken in the last 7 days. Take history of other substances used, prescribed and un-prescribed, and check medication prescribed by GP.

2. If the patient has collected and taken their dose of methadone on the day of admission no dose will be prescribed.

3. Review urinalysis results provided by keyworker over last two weeks and repeat urinalysis on admission.

4. History, physical examination, review/repeat FBC U&E LFT.

5. For methadone detoxification, consideration should be given to current dose taken (not necessarily the prescribed dose) and other substances used, evidenced by urinalysis results. Withdrawal symptoms should be measured using the Clinical Opioid Withdrawal Scale (COWS) (appendix). This should be carried out four times a day for the first 48 hours and then less frequently throughout the detoxification period to inform the prescribing practice.

6. If patients are on prescribed methadone, even if they give a history of taking additional methadone, the initial dose is their usual prescribed dose (or the dose they have been taking if it is lower). The methadone dose should not be increased unless withdrawal symptoms are objectively moderate in accordance with the COWS (score 13-24). Any increase in methadone must be discussed with and agreed by senior staff.

7. The usual rate of methadone reduction is 5-10 mg/day, and should be in line with the pre-admission plan. There may be some flexibility. It is desirable for patients to have 7 days methadone-free prior to

(31)

Page

|

30

discharge, to enable initiation on to treatment with naltrexone if required, as a relapse-prevention intervention.

8. Usually patients prefer to take their methadone dose in the morning and for some patients splitting the daily dose (bd) can be beneficial, however methadone should not be prescribed at night.

9. If any patient requires a dose of methadone over 100 mg/day they must have an ECG. In addition patients with other risk factors for QT interval disturbance should have an ECG either prior to admission or at admission.

10. Methadone must not be prescribed PRN. If an extra amount is needed it should be recorded as a single dose on the front of the drug card.

11. Patients who are not prescribed methadone before admission who make an informed choice to use methadone as their detoxification agent will not be given a first dose until they exhibit clear objective opiate withdrawal symptoms (COWS score 13-24). Forthese patientsmethadone doses will be titrated against withdrawal symptoms, as the risk of opiate toxicity which can be fatal outweighs the risk of unpleasant opiate withdrawal symptoms. The initial dose will be low, maximum 30 mg/day, and will be reviewed in line with the withdrawal scale monitoring. If this does not manage withdrawal symptoms adequately as evidenced by the use of the scale, discuss the patient and regime with senior staff and always consider the benefits of non-pharmacological supports and symptomatic relief with non-opiates as described above. After 48 hours the detoxification regime will commence as in point 7 above.

(32)

Page

|

31

Detoxification using Lofexidine

Although Lofexidine is not useful for detoxification for patients with very severe opiate dependence, there are circumstances where it may have a role. For example, where the patient has made an informed and clinically appropriate decision not to use Methadone or Buprenorphine, where they have made a decision to detoxify in a short time period, or where there is only evidence of mild or uncertain dependence.

For patients who are prescribed methadone who wish to detoxify with Lofexidine, treatment is more comfortable the lower the dose of methadone taken. Patients wanting Lofexidine detoxification should first aim to reduce their dose of methadone to 40mls/day or less.

Lofexidine is also useful as brief low-dose treatment for residual withdrawal symptoms after patients have stopped either methadone or buprenorphine.

Process

1. On admission check current dose of any prescribed medication with keyworker or community pharmacy. Ascertain from patient whether full dose has been taken in the last 7 days and take history of other substances used prescribed and un-prescribed and check medication prescribed by GP.

2. Review urinalysis results provided by keyworker over last 2 weeks and repeat urinalysis on admission.

3. History, examination, review/repeat FBC U&E LFT.

4. Consideration should be given to the proposed treatment regime agreed prior to admission detoxification.

5. Prior to commencing treatment, measure baseline B.P., sitting and standing. Treatment should not be started unless the systolic blood pressure is 90 mmHg or over, and the diastolic 55 mmHg or over. For the first 48 hours temp, blood pressure, respirations and pulse should be monitored four times a day by nursing staff. After 48 hours, BP and pulse to be monitored twice daily throughout the course of treatment. The systolic blood pressure should not fall more than 30 mmHg below the baseline level before giving the next dose. The diastolic should not fall below 50 mmHg and the pulse should not be less than 55 beats per minute. Omit next dose if BP or pulse are too low and discuss with prescribing medical team.

(33)

Page

|

32

6. Patients who have been receiving methadone or Subutex may commence Lofexidine on the last day of

treatment.

7. For regime see table below.

8. The dose for Lofexidine on drug sheets should be written as micrograms. Abbreviations are not acceptable.

9. Lofexidine may be introduced into a Methadone reduction schedule at a dose of 30-40 mg methadone mixture. The methadone is discontinued abruptly.

Typical Lofexidine Regime, N.B. Doses to be omitted if low pulse/blood pressure as

above:

Day Morning Lunch Teatime Bedtime

1 200 micrograms 200 micrograms

2 200 micrograms 200 micrograms 200 micrograms 200 micrograms

(34)

Page

|

33

Detoxification using Subutex (Buprenorphine)

Buprenorphine can be used effectively for short term inpatient detoxification. It is an alternative to methadone, although if patients are on doses of methadone greater than 30mg/day it is not recommended because of the risk of precipitated withdrawal symptoms. Buprenorphine is a partial opiate agonist with mild opiate-blocking properties. Prescriptions should be written as Buprenorphine S/L. Pregnant women should not be commenced on Subutex but if they are already prescribed when they become pregnant they can continue.

Process

1. On admission check current dose of any prescribed medication with keyworker or community pharmacy. Ascertain from patient whether full dose has been taken in the last 7 days and take history of other substances used prescribed and un-prescribed, and check medication prescribed by GP.

2. Review urinalysis results provided by keyworker over last 2 weeks and repeat urinalysis on admission.

4. Consideration should be given to the proposed treatment regime agreed prior to admission detoxification.

5. Patients can transfer to buprenorphine during a methadone detoxification if the methadone dose is reduced to 30mg/day (although transfer is easier if the dose of methadone is 15-20mg/day. Methadone is stopped and buprenorphine cannot be initiated until the patient displays clear withdrawal symptoms, which may not be seen for 48-96 hours (COWS score 13-24). Once in withdrawal the starting dose is 2-4 mg, and if tolerated an additional 2-4 mg can be dispensed on the same day. The dose can be titrated up on day 2 against opiate withdrawal symptoms using the objective opioid withdrawal scale. On day 3 the dose is reduced by 0.8 mg/day until drug free.

6. Patients on street heroin or other non-prescribed opiates/opioids or over-the-counter opiates/opiods may be commenced on buprenorphine once they have displayed clear moderate/severe opiate withdrawal symptoms as described in point 5 above.

(35)

Page

|

34

Detoxification from Stimulant Drugs

Patients with a predominantly opiate or alcohol problem often abuse stimulant drugs. The detoxification regime to be followed is for their primary drug of dependence. For patients who are dependent on street stimulants (mostly cocaine or amphetamines) there is no specific medication which has an evidence base.

Detoxification from stimulant drug use is usually managed symptomatically. The patients need to be reviewed on a regular basis by the inpatient doctor who can assess any problematic symptoms and prescribe accordingly. Consideration needs to be given to the physical problems associated with long term use of stimulants. Should symptoms persist, then the Consultant should be made aware and appropriate advice taken.

NICE guidance indicates that psychosocial interventions are appropriate with stimulant drug use, and one of the best forms of assistance is to provide a safe place where the resultant symptoms of withdrawal can be dealt with. Relaxation techniques and complementary therapies are particularly useful for this group of patients.

Withdrawal symptoms include low mood, agitation, lifelessness, fatigue and insomnia, are generally self-limiting and short lived. These symptoms can be treated symptomatically; however the mainstay is psychological support from staff. Low mood should not be assumed to be assisted by anti-depressant medication unless there is evidence after a minimum of 2 weeks, post completed detoxification, of depressive symptoms. Sedative antidepressants are not appropriate just to treat insomnia. Short term night sedation may be used in line with the night sedation policy (page 13).

If patients are on prescribed Dexamfetamine prior to admission, the withdrawal regime should be agreed prior to admission as part of the pre-admission process. The options are to abruptly stop Dexamfetamine on admission for small doses (5-0mg/day) or to reduce the Dexamfetamine prescription, aiming at a rate of 5mg per day. Agree the starting dose, max 60mg per day. Doses to be given early in the day, not at night and reduce over 5-10 days. If patients are not prescribed Dexamfetamine prior to admission, Dexamfetamine will not be initiated and their withdrawal symptoms will be treated symptomatically.

(36)

Page

|

35

Process

1. On admission check current dose of any prescribed medication with keyworker or community pharmacy. Ascertain from patient whether full dose has been taken in the last 7 days and take history of other substances used prescribed and un-prescribed and check medication prescribed by GP.

2. Review urinalysis results provided by keyworker over last 2 weeks and repeat urinalysis on admission. If urine is negative for amphetamines on admission, review the necessity for ongoing Dexamfetamine and review starting dose with advice from senior clinician.

4. Consideration should be given to the proposed treatment regime agreed prior to admission detoxification, as above.

(37)

Page

|

36

Benzodiazepines

1. Benzodiazepines will not be routinely prescribed or initiated during detoxification. In exceptional circumstances, if prescribing is commenced they will not be continued after the inpatient admission and should be stopped prior to discharge. If patients are prescribed benzodiazepines in conjunction with methadone prior to admission, it is recommended that the benzodiazepines will be reduced first and this can be achieved in the community prior to detoxification in some cases.

2. Patients who use illicit benzodiazepines are unlikely to require a prescription of benzodiazepines, as while use is common, dependence in this patient group is rare; refer to Benzodiazepine Guidance (appendix). Benzodiazepines can only be prescribed if there are clear withdrawal symptoms. The dose of diazepam must be titrated against symptoms:

Start with diazepam 5mg bd, morning and evening. Do not give at night.

Maximum dose 30mg/day.

Evidence suggests this dose will prevent withdrawal seizures after 24 hours.

3. Reduce the diazepam at approximately 20 percent of the dose each day. If 30 mg/day is not controlling withdrawal symptoms/signs, an urgent review is required by senior staff.

(38)

Page

|

37

Night Sedation

All patients withdrawing from substances will inevitably experience sleep disturbance to varying extents; they cannot expect to have normal sleep every night of their stay on the unit. Therefore night sedation will not be regular and should not be expected routinely as part of a patient’s treatment plan.

1. Every patient should receive a sleep hygiene leaflet and education during admission outlining non-medical methods of promoting a healthy sleep pattern.

2. If, despite these measures, the patient is still unable to sleep and has not slept for two consecutive nights evidenced by sleep charts (less than 4 hours sleep), Zopiclone may be prescribed.

3. Zopiclone dose range 3.75–7.5 mg for a maximum of seven nights on a PRN basis, to be taken on evidence of sleep charts confirming sleep deprivation. All attempts to resolve sleep issues should be supported by good sleep hygiene.

4. If patients are admitted on prescribed night sedation, confirm dose and length of treatment with their keyworker/GP and record any relevant information in the case notes. They should not be prescribed any additional night sedation. Attempts should be made to reduce/stop this medication if at all possible.

5. Pregnant patients should be discouraged from using night sedation unless essential (evidenced by sleep charts). If so, prescribe promethazine hydrochloride 25mg nocte.

6. Under no circumstances should patients be discharged on night sedation that is initiated during their stay at Hafan Wen.

(39)

Page

|

38

Relapse Prevention

Relapse prevention medication should be seen as an adjunct to psychosocial interventions and not as an alternative.

Naltrexone: For Opiate Dependant Patients

Naltrexone is an opiate antagonist used to reinforce abstinence in opiate users. It should be initiated by specialist services. Patients need to be opiate-free, confirmed by urinalysis for Methadone which has a long half-life.

Methadone Naltrexone test dose after 7-10 days. Buprenorphine Naltrexone test dose after 3-5 days.

Patients must be fully informed of the risks and benefits and observed closely for 4 hours following the test dose of 25mg Naltrexone. They may experience mild withdrawal symptoms. If this dose is tolerated the dose is increased to 50mg daily. Long-term prescribing is arranged with the Community Drug and Alcohol Service.

Check LFT and gamma GT before starting naltrexone. Naltrexone can be given with mild abnormalities of liver function after a risk/benefit analysis. LFTs should be checked 3 monthly in the community while on this medication.

Taking large amounts of opiates can overcome the effects of naltrexone and cause fatal overdose. Patients should be advised of this and should sign a consent form.

Acamprosate

Acamprosate is currently licensed for relapse prevention in alcohol use disorders in the UK. Acamprosate primarily reduces glutaminergic activity in the brain with some effect on increasing GABA-ergic activity. Clinical evidence for Acamprosate suggests an increased chance of remaining completely abstinent from alcohol in subjects classed as at least moderately dependent on alcohol. Acamprosate is usually prescribed at 666mg tds (for patients >60kg) and 666mg morning, 333mg lunchtime and night (for patients <60kg). It is normally prescribed for 3-6 months but could be longer for patients who are benefitting and wish to continue.

(40)

Page

|

39

Disulfiram

Disulfiram is an alcohol dehydrogenase inhibitor and is licensed for relapse prevention in alcohol use disorders in the UK. Disulfiram taken supervised can be an effective component of relapse prevention strategies. The decision to start treatment is complex. Discuss with senior staff and document. NICE guidance suggests it is a second line treatment if Naltraxone/Acamprosate is not suitable or the patient prefers Disulfiram. Supervising arrangements should be agreed and documented; a carer if agreeable can supervise if they are fully informed and understand the risks if the patient drinks alcohol.

Disulfiram therapy can be started towards the end of inpatient treatment. It should be started only after the patient has abstained from alcohol for at least 24 hours, ideally 48-72 hours. The dose is 200mg daily. The patient must be aware of the potentially serious consequences of drinking alcohol with Disulfiram. Disulfiram may react even with small amounts of alcohol found in over-the-counter cough and cold

preparations and any medication that comes in an elixir form. Alcohol may also be found in some toiletries e.g. aftershave.

Baclofen

There is some evidence to support the use of the GABA-B agonist baclofen in relapse prevention for alcohol dependent patients following detoxification. The limited evidence available to date suggests that baclofen may be more effective in severe dependence.

Baclofen is not currently licensed in the UK for alcohol use disorders. It does appear to reduce alcohol craving and reduce anxiety in alcohol dependent patients post detoxification. Baclofen is a second line treatment for relapse prevention, always discuss with senior staff before commencement.

Starting dose 5mg tds. The usual treatment dose of baclofen would be in the range of 20mg to 40mg daily in divided doses. Common side effects include fatigue, headache and constipation but most patients tolerate the drug well. Baclofen should be prescribed for 3-6 months (or possibly longer in some cases). It is important for the patient to remain under review and to maintain regular contact with the keyworker.

(41)

Page

|

40

Naltrexone following alcohol detoxification

Naltrexone can also be used as relapse prevention medication in alcohol dependence following detoxification. Naltrexone is not licensed in UK for alcohol use disorders but is licensed in US and is approved by NICE. The dose of naltrexone is 25mg daily increased to 50mg daily if tolerated. Side effects include nausea, headache and hepatotoxicity. LFT monitoring should be arranged as indicated above. Patients also need to be aware of the blockade effect on opiate analgesics. Treatment is usually for 3-6 months but may be continued for longer in some cases. The main evidence for naltrexone is reduced rate of relapse to heavy drinking and reduced alcohol consumption. The evidence for abstinence is more limited.

(42)

Page

|

41

Therapeutic Programme

Psycho-social interventions play a significant part in the treatment of drug and alcohol use disorders (DoH, 2007; NICE, 2007; NTA, 2005; Welsh Assembly Government, 2005). National UK guidelines state that a full programme of psycho-social support should be in place during and following detoxification (DoH, 2007).

The therapeutic programme at Hafan Wen is informed by the Lifestyle Balance Model, which is an evidence-based psychological model that draws heavily from cognitive-behavioural principles. The therapeutic programme enables service users to gain a deeper understanding of the functions of their substance. It will allow them to identify particular areas of concern for them.

By drawing on a range of evidence-based techniques drawn from a variety of approaches such as (Motivational Enhancement Therapy, Cognitive Behavioural Therapy, Mindfulness, Acceptance and Commitment Therapy, Node-link Mapping, Relapse Prevention), service users will be able to develop a range of coping strategies to intervene in a way that best suits their particular needs. A rolling programme of Group and individual key-working sessions will enable staff and service users to draw on these latest evidence-based psycho-social approaches in a highly systematic way.

The core therapeutic programme enables service users to understand the “drivers” of their substance use and to develop the skills to manage these aspects without the use of substances. The Lifestyle Balance Model enables service users to begin to make the lifestyle changes necessary to manage their recovery.

Hafan Wen ensures:

That treatment will support individual needs as appropriate.

That in addition to pharmacological treatments, interventions will include provision of a range of psychosocial group and individual based interventions, relapse prevention work, education and social skills, as well as peer support and self-help options (i.e. mutual aid groups such as AA/NA/SMART).

Delivery of evidenced based psychological interventions that are integrated into all aspects of work with service users.

(43)

Page

|

42

Delivery of individually tailored Psychological Interventions that typically include behaviourally and/or cognitively focused approaches.

That Staff are competent in psychological therapy to develop individualised care plans and are able to deliver them.

That staff receive on-going supervision to ensure fidelity to the approach

Appropriate environments for delivering psychological interventions

That the efficacy of the psychological interventions are evaluated

Relapse Prevention and Prevention of Drug Related Deaths

That in partnership with the service user and their care co-ordinator, there is a comprehensive aftercare plan in place before the individual is discharged.

The delivery of relapse prevention training using a variety of evidence based behavioural and cognitive strategies to enable service users to identify high-risk situations for return to alcohol or drug use and equip them with the skills to reduce the risk of relapse.

That information about preventing drug related deaths is given to all service users whilst in Hafan Wen.

Referral

Hafan Wen monitors the smooth running of the agreed referral pathways into the clinic through regular communication and liaison with referrers. This collaborative approach reduces treatment barriers and ensures all service users referred to in-patient detoxification are appropriately prepared and have a comprehensive discharge plan in place, outlining aftercare arrangements. Where identified as part of the ICP Hafan Wen aims to link detoxification admission and discharge dates to coincide with rehabilitation start dates and or other treatment modalities, including community settings or abstinence based support, ensuring continuity of care

(44)

Page

|

43

Assessment

Prior to admission, Hafan Wen, the referring agency (community provider) and the service user develop an individual care plan based on a thorough assessment of need that reflects the required treatment pathway (ICP) and duration of stay.

Testing to aid identification of recent substance use Assess signs of withdrawal where present

Take a history of drug and alcohol misuse and any treatment including previous attempts at detoxification.

Review current and previous physical and mental health issues, and any treatment for these.

Consider the risks of self-harm, loss of substance tolerance and misuse of drugs or alcohol as a response to withdrawal symptoms.

Consider the person's current social and personal circumstances, including employment and financial status, living arrangements, social support and criminal activity.

Following agreement of confidentiality boundaries with clients upon their admission, services should seek to keep carers informed of their progress in treatment – including being informed and involved in the formulation of a discharge and aftercare plan (within which they may play a key role).

Wherever appropriate, carers should be informed of any unplanned discharge in order to prepare them for the possibility for clients coming to their homes and asking to stay.

Carers also need to be informed of the risks associated with overdose and the signs and symptoms to look for.

Develop strategies to reduce the risk of relapse, taking into account the person's support network, and will incorporate any required actions to address these into the individualised care plan.

(45)

Page

|

44

Pre-Admission

Development of admission and post-admission care plan

Agreement with senior team doctor of proposed medication regime, length of stay Completion of the ICP

Routine blood investigations within 2 weeks prior to admission; FBC, U&E, LFT; and for alcohol admission Gamma GT

Two full urine screenings in 4 weeks prior to admission for individuals using illicit substances or on substitute medication, including benzodiazepines and opiate-based pain relief

For female patients requiring Lofexidine detoxification or treatment with buprenorphine, it is important to rule out pregnancy before admission. A pregnancy test should be carried out prior to admission if appropriate.

If a patient is open to a CMHT and requires inpatient treatment at Hafan Wen for detoxification or stabilisation, the following pre-admission steps should be taken.

Keyworker to liaise with CMHT care co-ordinator to ensure:

1) Up to date sharing of risk assessment and other clinical information.

2) Confirmation of medication prescribed for treatment of the patient’s mental illness, and agreement on which medications need to be continued during admission. (This may include benzodiazepines and night sedation).

3) A copy of the patient’s early warning signs and crisis plan to be shared with Hafan Wen staff during admission.

If the case is complex a pre-admission multidisciplinary or CPA meeting will be held.

For some admissions it is recognised that blood screening may not have occurred. This will not prevent admission for any patient.

(46)

Page

|

45

Admission and Eligibility

All admissions to Hafan Wen are made as part of a planned and on-going integrated plan of care. All service users will be aware of their admission date and arrangements will have been made by their community workers to ensure their safe arrival at the Clinic.

On admission the service user will be greeted by Hafan Wen staff and will be seen by the admitting medical doctor.

Based on our eligibility criteria we would not be able to offer the following service to the following clients who are identified as being in need of medical/mental health services considered to be beyond the capacity of our medically monitored service provision:

Patients with acute psychiatric morbidity or on sections of the Mental Health Act. Patients with serious physical morbidity

Patients who have high risk of violence Patients cannot be bailed to Hafan Wen

(47)

Page

|

46

Discharge

All discharges, including those for breach of unit rules require careful consideration and robust risk assessment as per agreed ICP. For the majority of admissions discharge dates will be agreed pre-admission and the aim would be for all discharges to be planned as part of the agreed treatment plan.

Urine screening alone should not be sufficient to precipitate discharge for breach of rules without medical team agreement that treatment is compromised, and it should be recognised that urine screening can lead to both false positive and false negative results, and potential legal redress. Discharges are accountable to the senior management and Consultant. Where there are difficulties, discuss with the Consultant and senior manager, or if that is not possible, discuss with other senior medical staff.

In the case of vulnerable adults, pregnant women, safeguarding children, discussion should take place with senior management/medical staff and community staff. Violent episodes and threats will not be tolerated. Staff will utilise police support where necessary.

It is recognised on some occasions that discharge will be taken early with medical agreement and on occasion against medical advice. To minimise risk to the individual and others, immediate and comprehensive liaison with the relevant keyworker is imperative to ensure any identified risks are shared and contingency planning communicated by Hafan Wen staff. Discharge for breach of rules is a joint decision between Hafan Wen staff and the inpatient medical team and still requires a risk assessment to be documented and should be a rare occurrence, based on objective evidence.

BCUHB policy is that no more than seven days discharge medication should be given to a patient to take home. For Controlled Drugs and benzodiazepines, if they are required for treatment after discharge, nursing staff should liaise with community workers to ensure continuity of treatment; so ideally community treatment with these preparations will be organised prior to discharge and no take-home supplies will be needed. If this is not possible, take-home Controlled Drugs and benzodiazepines should be given for as short a time as possible, preferably no longer than one or two days.

A short discharge summary should be completed by inpatient nursing staff immediately and copies sent by fax to the GP and the substance misuse keyworker. A full discharge letter should be completed by the medical team and sent to the GP and keyworker within agreed BCU timescales.

(48)

Page

|

47

Aftercare

Following discharge, service users will be followed up by their referring community drug and alcohol teams as planned.

Service User Involvement

CAIS’ core values demonstrate the organisation’s regard for service users in that it values: A Person Centred approach (to its service users and staff)

Unconditional Positive Regard Empathetic understanding Empowerment.

These values were developed with staff in consultation with service users which provided a foundation for continued focus on quality, patient centred care, dignity, respect and a non-judgemental approach.

Hafan Wen’s Service user focus can be demonstrated by the level of involvement in their care planning e.g. The clinic doctors review client’s medical withdrawal on a daily basis and consult with the service

user in relation to dosage, rate of reduction and any other factors that contribute to the likelihood of the user completing their detoxification regime comfortably and successfully.

We ensure the views and experiences of the service users, carers and representatives who use our services are listened to and influence our service development. The clinic makes use of a resident’s suggestion box and feedback from a service user satisfaction questionnaire that is reviewed monthly.

We actively seek service user feedback through our User satisfaction questionnaires and ex-service user group. The resulting data is used to review the robustness, outcomes achieved and suitability of our services, as well the way that our staff operate the services and interact with the service users.

Hafan Wen has utilised past information to build on its strengths and consider the gaps in the provision of service. This has enabled the clinic to modify and build on the information received to improve services.

(49)

Page

|

48

Specific examples include:

Food/kitchen

Therapeutic Programme Ex-service user group Urine testing

Pre admission management of expectations

Ex-Service User Involvement

Our existing ex-service user group, comprising of six ex- Hafan Wen residents who are actively involved in community based recovery groups have a nominated person who represents service users on the Hafan Wen Stakeholder Group. The ex-service user group, in addition to providing current service users with advocacy and peer support also gather client satisfaction data that help to identify areas for development and improvement. Information gathered by the ex-service user group is communicated to the Stakeholder group who then recommend developments to Hafan Wen management.

(50)

Page

|

49

SECTION FOUR

QUALITY

(51)

Page

|

50

Quality Improvement Model

CAIS is registered as a member of the Wales Quality Centre and as such has adopted the European Foundation for Quality Management (EFQM) Excellence Model. The main concepts of the Excellence Model are for organisations to identify and act upon identified strengths and areas for improvement based on self-assessment and assessment by other member organisations of the Wales Quality Centre.

CAIS is a Welsh Assembly Government Approved support provider for the Supporting People initiative and has achieved and retained Investors in People status for over ten years.

Hafan Wen is registered under and regulated by the Health Inspectorate Wales (HIW) who undertake annual and imprompt