Throughout all our services we structure our care around Care Pathways specific to an individual service user’s assessed needs. These pathways allow us to outline anticipated care, set appropriate timeframes, and help our service users move progressively through a clinical experience to positive outcomes.
Our Care Pathways also support the development of care partnerships and empower both service users and their carers. We also use them as an essential tool to incorporate local and national guidelines into everyday practice, manage clinical risk and meet the requirements of clinical governance.
Assessment & Treatment Pathway
(up to 20 weeks)
Our Assessment & Treatment Pathway offers a comprehensive assessment by our specialist multidisciplinary team, allowing service users to access services in a timely manner, and can offer a rapid transition for those in crisis who need urgent admission.
This pathway focuses on reducing any potential psychological and emotional distress, treating mental and/or physical illness, and formulating a person-centred care plan.
Our findings and recommendations are clearly presented at a Care Programme Approach (CPA) meeting at week 12, and where relevant allowing for a planned and coordinated transition to conditions of less restriction over the following weeks.
When progress has been possible to facilitate community discharge, we provide a comprehensive Positive Behavioural Support (PBS) plan to inform future placements of appropriate behavioural support strategies, coupled with pharmacological therapies to help maintain the positive results achieved during the individual’s stay with us.
We also work collaboratively with the community placement to deliver a smooth transition and deliver network training if required for the new team.
If the individual requires further treatment on one of our specialist care pathways, this will also be discussed in the 12-week CPA meeting.
Rehabilitation Pathway
(timescale dependant on CPA)
For those with co-existing mental illness, personality disorder, forensic risks or complex behaviours that challenge, rehabilitation can require a longer period of specialist assessment and treatment in a hospital setting.
Our Rehabilitation Pathway focuses on formulating and evolving an individualised, person-centred PBS plan that provides individuals with enhanced support and responds to risks, whilst maximising quality of life.
The aim of this pathway is to actively engage individuals in moving towards community living. A key component of this pathway is the application of principles of active support in order to assist individuals in achieving their own person-centred goals, which will assist them in achieving both short and long-term goals centred around rehabilitation and community participation.
Individuals on our Rehabilitation Pathway are offered a wide range of unit and community-based activities that improve their overall wellbeing; establishing therapeutic alliance and, wherever possible, reducing the use of pharmacological treatment.
Forensic Pathway
(timescale dependant on individual need)
For those with specific forensic risks a Forensically-Informed Psychological Intervention Pathway is available.
This pathway is available to individuals who present with the following risks:
- Verbal threats to harm
- Physical aggression (inc. environmental damage)
- Intimate partner violence (emotional, verbal and physical)
- Sexually harmful behaviour (threatened/attempted/actual assault, inc. possession of indecent images)
- Fire-setting
This pathway is delivered by the psychology team on a group and/or individual basis dependent upon the needs of the individual. The aim of this pathway is to reduce identified risk by giving service users the skills to deal with potential destabilisers in the future.
The pathway is built around structured modules and session plans, however these are adapted and individualised to meet specific needs.
Outcome measures, including development and review of forensic risk assessments, are used to evaluate progress.
Adapted DBT Pathway
(timescale dependant on individual need)
For those with a diagnosis of emotionally unstable personality disorder, or who present with emotional/relational instability, an adapted Dialectical Behaviour Therapy informed pathway is available. This pathway is based upon delivering the DBT modules of mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance.
This pathway is delivered through individual and group treatment sessions, as well as through reinforcement of DBT skill use by nursing and support staff. Materials and session plans are based upon the DBT model but adapted to meet individuals’ specific needs and cognitive abilities.
Outcomes are measured on standardised assessments as well as feedback from clients and progress along their rehabilitation pathway. CBT and trauma-focused interventions are also available.
Complex ASC Pathway
(timescale dependant on individual need)
For individuals diagnosed with an Autistic Spectrum Condition, or presenting with traits related to this condition, the following interventions are available based on individually assessed need:
- An ASC-friendly environment
- Speech and Language Therapy assessment and intervention
- Augmentative communication
- Structure and predictability
- Sensory assessment and intervention
- Social stories to promote engagement in activities of daily living, community participation, and understanding of social situations
- Visual Aids to support routines
Complex Behavioural Pathway
(timescale dependant on individual need)
Individuals placed within our hospital environments who are identified at initial assessment / pre-admission as presenting with high levels of behaviours that challenge (including multiple or complex behavioural issues, significant psychological distress or unstable mental health difficulties) are placed on this pathway for input from nursing, psychiatry, psychology and multidisciplinary professionals i.e. OT & SALT.
Assessment will include:
- Review of history and background information
- In-depth functional analysis assessment
- Direct observations, monitoring and specific assessments of service user by multidisciplinary professionals
Intervention will include:
- Service-wide PBS informed practice
- MDT input into Care and Treatment Planning, and Risk Assessment and Management Planning
- Development of service user PBS plan
- Review and monitoring of PBS plan implementation through positive monitoring
Recovery and Wellbeing Pathway
For those with brain injury and progressive neurological disorders, behaviours that challenge can require a longer period of specialist care and treatment in a hospital setting.
Our Recovery and Wellbeing Pathway focuses on formulating and evolving an individualised care plan that provides these patients with enhanced support and responds to risks, whilst maximising their quality of life.
People with progressive neurological conditions can often present with complex psychiatric and physical comorbidities; this pathway provides a framework to assess and treat mental illness, enhance functional ability, and promote independence through engagement in a variety of evidence-based therapies.
Patients on our Recovery and Wellbeing Pathway are offered a wide range of unit and community-based activities that improve their overall wellbeing; establishing therapeutic alliance and, wherever possible, reducing the use of pharmacological treatments. They also have daily access to specialist communication and swallow assessments, provisions of specialist feeds (including PEG), physiotherapy, specialist GP and dental services, occupational therapy and dietetics.
Specialist Palliative Care Pathway
The behaviour of a small number of our patients can remain challenging as they enter the terminal stages of their illness.
In partnership with St David’s Hospice, we have developed a Specialist Palliative Care Pathway that provides for those that are unable to transition to a nursing home or hospice setting. We also work closely with these patients’ families to support them and their loved ones during this time.
