DRYLL Y CAR
SUPPORTING PEOPLE THROUGH ALLIANCES
INTRODUCTION:
Gwynedd Community Unit NHS Trust provides mental health service for the bilingual population of Gwynedd, North Wales. The service is broken down into five sectors served by community mental health teams (CMHT). The population of 243,327 (1991 census) is served by a District General Hospital unit of fifty-four beds in Ysbyty Gwynedd, Bangor.
Meirionnydd sector, population 33,100, is both remote from the District General Hospital unit, and sparsely populated. Its most remote town is Aberdyfi eighty miles south of the District General Hospital unit.
The economy is rural, with hill farming and tourism predominating. Traditional industries such as slate quarrying are in decline, and there are areas of very high unemployment.
Many communities within Meirionnydd are very distant from the main serving psychiatric facilities. The most distant have been known to use hospitals in Welshpool and Talgarth due to there being closer than the county facilities. Relatives and carers travelling to Bangor to visit often had to stay over and return the following day.
People needing help using a residential base were forced to use acute admission beds even though they may not be acutely ill. The alternative to this would be sessional support from the Community Team when what was needed was more intensive work which could be provided quickly and locally.
DRYLL -Y- CAR:
Dryll y Car is an eight bedded community support unit in Barmouth, Gwynedd. In a building that was previously a bed and breakfast establishment, we have succeeded in retaining the guest house atmosphere. We are very aware that to provide a good service means moving away from the traditional approach of responding to crises. Our role is essentially in supporting people, being accessible when problems arise and working alongside clients to attain, prolong and sustain good mental health. We offer the clients choices. It is always clear that they retain the power to choose. All users of the service are counted as part of the team, but there are a number of users who perform specific functions within the unit. . Some attend to the gardens while others provide support for the staff within the unit. Our main objective is to provide a good experience for everyone who is involved in the service, both staff and clients.
The unit was opened to provide a local alternative to District General Hospital admission for people with acute mental health problems, as well as offering planned admissions, rehabilitation and respite care for people with enduring mental health problems.
PHILOSOPHY
The long term purpose of Dryll Y Car is to develop partnerships with clients which will promote increased and persistent mental health.
We aim to provide a community based residence where people in Meirionnydd may access a high standard response to their needs without travelling long distances, or having to be admitted to a psychiatric hospital.
We further recognise the importance of empowering clients to develop networks of support within their community.
THE TEAM
The staff team consists of a Nurse Manager, six Staff Nurses, a Clinical Assistant in Psychiatry and six Health Care Assistants. The team meets formally once a month to discuss policy issues and work on ways of moving forward together. There is a flattened hierarchy, so that although each person has a distinct role in the running of the unit, everyone has an equal say in what happens. Just as we empower clients by allowing them to take responsibility for their own lives, so the management style is to inspire members of staff to undertake new initiatives, and support them in developing these initiatives in their own way. As we empower clients to own their own experiences so we empower members of staff to own their own initiatives. The team are very supportive towards each other, there is a formal supervision group, but most of the support takes place informally both inside and outside work and over the phone. There is an informal agreement that the nurse in charge can gain telephone support from the managers or consultant at any time.
Members of the team also meets informally once a month in a local pub to enjoy each other's company in a more relaxed setting.
Clients View: One big advantage of being somewhere like Dryll y Car is that the management is human, not in the least dictatorial. To give just one example, at present there is some talk about changing the function of some of the rooms. A letter and diagrams explaining the possible options, and a request for other ideas as well, was circulated to all current users of the service and staff.
Although as clients we have a primary care team that our admissions are planned around, should we feel the need to have a session with another member of staff who has a particular expertise in a certain field that we could find helpful then there is no problem in seeing that member of staff. Among fellow service users we often refer to this enlightened attitude as a 'pick and mix' service.
I see the management style of Dryll y Car as a hierarchy of equal partners wherein each member of staffs skills and input are of equal importance in the successful running of the unit. Rather like a football team, in which each player has their allocated position but success depends on each player's contribution and how well they support each other.
The counselling, therapies and social interaction that take place in a relaxed and friendly and mutually supportive atmosphere facilitate the rediscovery of feelings of self worth, confidence and a positive attitude towards the future. One of my greatest regrets is that there was no Dryll y Car in existence thirty five years ago.
WORKING AT DRYLL Y CAR:
Working at Dryll-y-Car is by no means an easy option, the workload is immense. The unit is isolated, nearly two hours drive from the nearest acute hospital support, and the staffing levels are not high, usually one staff nurse and one or two HCAs for eight inpatient beds and up to ten outpatient contacts a day plus providing telephone support to distressed clients who ring in.
The ethos of partnership with clients means that the nursing staff have less control over what happens on the unit than would otherwise be the case, and there has to be a certain amount of risk taking which the staff can find stressful.
Taking risks means allowing the people in our care to be in control of their own lives, not us being in control of theirs. It means allowing people to make mistakes and learn from them. It means not just listening to people, but hearing what they are saying. It means allowing people to own their own experiences, be responsible for their actions. It means recognising the validity of other's experiences.
For nurses this is not an easy thing to do. It means a far greater degree of individual responsibility than the traditional role, it means giving more of yourself. Sometimes it means sticking your neck out. This is only possible in an atmosphere of mutual trust with ones colleagues and with managers that recognise that we are not responsible for decisions that service users take about their own lives.
The Dryll y Car staff team does provide the supportive environment in which this kind of risk taking can take place.
PROTECTING RESOURCES
There is a common recognition that our most important asset is the staff team and within the team the most valuable resource is the individual staff member.
We readily recognise the importance of protecting our assets and so we make sure that Dryll-y-Car is a good place to work and that the staff enjoy coming to work. We have endured the effects of some unavoidable illnesses, personnel changes and staff reductions but casual sick leave is virtually non existent.
ADMISSION ROUTES:
Dryll y Car works as a part of the Meirionnydd Community Mental Health Team(CMHT). The Team consists of CPNs, social workers, psychologists, psychiatrists and Occupational Therapists who work as a multi disciplinary team. The team have a number of initiatives for including service users in service provision and educating clients about self management of mental health problems.
All clients who come to Dryll y Car have a care manager from the Community Mental Health Team . The care manager is included in the pre admission assessment and provides a care plan on admission. On discharge the care manager is involved in the drawing up of discharge care plan which details the support that the team and the unit will provide for the client whilst they are at home. This may involve the input of community support workers.
We also work with the Gwynedd Mental Health Advocacy Scheme, both encouraging our clients to use the service to increase the amount of support they get in the community, and also to act as volunteer advocates for the service.
Clients View: The relationship between clients, care managers and support workers is a true partnership which provides an integrated network that enables a client to function more effectively in their daily lives in the community. When at home the knowledge that help and advice is only a phone call away at any time of the day or night, provides a sense of security that enables one to manage better.
ADMISSION CRITERIA:
The admission criteria for Dryll y Car are deliberately fuzzy. Most referrals come through the Meirionnydd Community Mental Health team, but we also assess anyone who thinks they might benefit from the service. This includes self referrals/referrals by families. All clients have a care manager from the CMHT. Assessment is a process of coming to an informed agreement between the prospective client and the staff group of what the person can expect from the unit, and what we expect of them. Partnership has to be an agreement between both parties. In only 4 cases have we been unable to offer a service to clients who have been referred to us.
FUNCTIONS OF THE UNIT:
The ethos of Dryll y Car in providing client led services means that we fulfill a number of functions according to client need:
1. To provide a therapeutic environment in their local area for clients in the process of returning home after an admission the Hergest acute unit in Ysbyty Gwynedd.
Clients who have recovered from the more acute stage of their problem can be transferred to Dryll-y-Car for a short period to ease their passage back into everyday life. Being nearer to their home area it is easier for a client to spend time with relatives and go home for a few hours to prepare for discharge.
This period also gives the client the opportunity to get to know the staff on the unit so that they feel able to call us for support in times of difficulty and so avoid readmission to the acute unit.
2. To provide assessment and review of clients in the community to ascertain the most appropriate use of mental health services.
Our starting point is to assess the nature and extent of peoples' needs. Having done this and set in motion a plan, it is necessary to review progress.
Clients are assessed for a variety of reasons and at different points in their contacts with us. For example we will admit or see people to determine optimum levels of medication, the assessment of basic social and living skills or to clarify underlying problems that lead to self harm. We will also assist in the assessment of required levels of help for persons with organic conditions such as early onset dementia to enable home care to continue at a level complimentary to the clients ability.
At the conclusion of an assessment or review period the client is either offered a package of care from Dryll-y-Car or linked in with the correct agency.
3. To provide a 72-hour bed for clients experiencing short term problems in order to avoid admission to Ysbyty Gwynedd and to promote client led proactive use of ways to stay well.
A nominal bed is kept open for immediate admission of clients who have already spent some time on planned admission to Dryll-y-Car and are known to the team. This service is offered as part of an agreed after care package and is subject to review. The knowledge that there is a bed available should the need arise is often sufficient support for people to be able to cope.
4. To provide regular planned admissions to allow therapeutic interventions towards the resolution of long term psychiatric and skills problems
After a period of assessment most clients are offered a series of planned admissions, usually a week every month to six weeks, to undertake specific, planned interventions to overcome their life problem
By responding at times other than a crisis we aim to consolidate the clients' sense of being well and avoid further disabling them .
Most psychiatric admissions are a response to a crisis, which is not a time when most people can make reasoned and objective decisions about their lives. The staff at Dryll-y-Car encourage clients to continue working on their problems preferably when they feel well, as this is the most useful time to seek long term solutions to their mental health problems. In other words the aim is to provide ongoing treatment while the person is well rather than only respond to a crisis.
A further aim is to help clients with poor life skills to work on a progressive series of achievable goals and then return frequently to their home to practice them. The advantages of this approach are:
1. The client can use his/her home which provides a realistic bench mark for the work in the unit. Unanticipated obstacles are identified at an early stage.
2. The disabling effects of long term admission are avoided
3. There is an onus on the client to report progress or problems which add to the partnership principle.
Client View: Regular admissions to the unit provide the opportunity of reinforcing the progress that has already been made and continue that progress. Re-admission to Dryll y Car is like revisiting home to meet much valued friends.
Husbands/wives are actively encouraged, after consultation with the client, to become involved in the ongoing care plans which are always drawn up on discharge.
5. To provide regular planned admissions for respite care.
Some clients come in to the unit regularly to reduce the load on carers. The times of these admissions are negotiated with the carers to allow them to use time effectively, for example to go on holiday.
We feel that this adds to the quality of both the clients and the carers life. Often clients are still active in making these choices but there is an advocacy role in admitting clients who cannot actively decide as quality time out for the carer often means better quality time "in" for the client when they return home.
6. To provide a twenty-four-hour support network for individuals in the community.
This may range from a telephone call to an informal visit or regular day case work to continue on going therapy. Many clients are treated on an outpatient basis. Some only come to the unit as outpatients, others use a combination of inpatient and outpatient visits.
Clients who come through Dryll y Car are offered on going support either by telephone or by visiting the unit whenever they feel the need. The availability of someone they know at the end of the telephone, and the reassurance that a 72-hour admission is available is perhaps the best support that can be provided in the community from a support bed unit.
There is a need to balance the demands on the unit from internal and external sources to maintain the optimum service to clients. All these options are negotiated as part of an after care package involving Dryll y Car staff, care managers, clients and significant others and are regularly reviewed.
THE FAMILY:
No list of therapies available or functions undertaken in Dryll y Car could give an indication of the true value that the Dryll y Car experience means to our client group. It is a place where they are accepted for who they are, where they have many friends, a place where they can relax and be themselves. We do not care for our clients as that would be to disempower them, but we do care about them.
A family is something that gives most of us an inner sense of security, it is somewhere that we can always go back to for support in times of crisis, a place where we can be accepted unconditionally for who we are. People who have enduring mental health problems are often those who have never had the experience of a secure family background, but Dryll y Car provides a family environment for our client group, allowing them to lead their own lives with the security of knowing that help and support is always available. Dryll y Car is referred to by many people as 'The Family'
Clients View: As a user of Mental Health Services I have found Dryll y Car to be a unique and empowering experience. The family atmosphere, in which everyone is equally important, equally respected and everyone's opinions are listened to and valued dispels the dreadful feelings of hopelessness and helplessness that can accompany mental illness. One is no longer caught up in a system over which one feels one has no control.
The quality of all the staff, the friendly and very supportive atmosphere at Dryll y Car has played a large part in my being able to come to terms with my mental health problems, and to start to be able to spot potential mood swings before they get out of hand. This in turn is making my home life considerably less stressful for my partner who has been finding it harder to cope with my previous unpredictable mood swings.
Knowing that I have access to the 72 hour crisis bed if I start to have problems at a weekend is often enough to enable me to cope. Weekends can be a major problem in such a rural area as Meirionnydd where, apart from the Hergest in-patient hospital in Bangor, there is little else available.
ALLIANCES AND EMPOWERMENT:
The service is constantly evolving as a result of dialogue between staff and clients. Over time the average length of admissions has reduced. This allows more focused care, whist allowing us to support a greater number of clients. Most clients stay for one week at a time. The timing of admissions coincides with when their primary care team is on duty. Each admission has a clearly identified, realistically achievable goal identified in a care plan that is agreed between the client, primary nurse and care manager from the Meironnydd Community Mental Health Team. Most clients have a regular series of admissions to help them move forwards to meet the evolving challenges of their lives. As clients remain immersed in their own lives and families, we are in a much better position than conventional services to work with partners, families and children, and to support people through making changes to their lives. Those changes often involve retraining, further education, and reintroduction to the work environment. We have close ties with local housing associations and the local authority in order to help people find more suitable accommodation. We also encourage clients to participate in a range of activities such as abseiling, pottery, art therapy, and visits to the theatre, opera or ballet and local leisure centre. There are regular meeting in which clients can express their views of the service and make suggestions for improvements.
EXPLORING ALTERNATIVES:
The use of medication is kept to a minimum, but to do this means spending time with the clients exploring alternative ways of coping:
LEISURE CENTRED
Recent negotiations with the local leisure centre have enabled us to offer supervised exercise and leisure activities to some clients on a "prescribed" basis through our clinical assistant who checks physical baselines and subsequent progress.
TECHNO TRIALS
We have recently acquired three pieces of new technology which we are evaluating for their therapeutic effect:
1. The Mind Lab
The Mind Lab uses synchronised pulses of light and sound to emulate particular brain wave patterns recognised as being associated with certain mind states from active alertness to meditative states. It can be programmed to induce sleep, relaxation or alertness. Initial results are encouraging. One exciting prospect is that we may be able to use this machine to erase nightmares. This is a significant problem for people who have a post traumatic stress disorder.
2.The Dream Machine
The Lucid Dreaming machine is a mask worn at night. It detects when the wearer is dreaming, and gives cues that allow the wearer to gain conscious control over his or her dreams. This may also be useful for clients whose sleep is disturbed by recurrent nightmares.
3.SAD Light
Seasonal Affective Disorder (SAD) is a condition in which people become depressed in the winter due to reduced exposure to light. We have been offering Phototherapy to suitable clients by exposing them to 10,000 lux UV - filtered light for up to one hour per day during the relevant period for each person. The effect of the light is measured by the assessment of the persons mood state using a standard measure. ( Beck)
4. The Banana Chair
This chair is especially designed to aid relaxation, and can be used in conjunction with the Mind Machine and soothing musicto promote total relaxation
SUMMARY
The team in Dryll y Car strive to offer a person centred service for those with a wide range of mental health problems. We share a common ideal that people with mental health problems should be listened to and that our own explanatory language should take second place to the concerns of those we are to help. We strive to strike a balance between our own professional skills and recognising the strengths of those we are helping. This guides our work in developing novel techniques to help people with distressing experiences such as hallucinations, which do not always respond to medication. This is made possible by the team work of the different disciplines within the unit, which also includes service users as equal members of the team.
Comments received about Dryll y Car by the Mental Health Users Forum:
'Dryll y Car in particular came in for particularly high praise with not a single negative comment. This is the third time in the past 2 years that Dryll y Car has come in for such high praise from the service users who have been resident there'
'Dryll y Car came in for it's usual high praise, homely environment, good furnishings, able to see notes etc.' (from The Way Forward, Mental Health Users Forum 1996)
It is easy to air your own views
The nursing staff are very supportive and caring
Staff are open and friendly
Nursing staff are very good, including the health care assistants
The unit is so friendly.
The Dryll y Car team was a finalist in the 1996 Hospital Doctor 'Psychiatry Team of the Year' Awards.
Dryll y Car were awarded the 'Demonstrating Excellence - Quality in Practice' Award in . 1998