10 March 2020

PSA C/O Alexandra Ward

PSA House
11 Aurora Terrace
Wellington Central
Wellington 6011

Email: alexandra.ward@psa.org.nz

Dear PSA

Re: 20200210 Letter of Concerns

Thank you for your letter dated 10 February 2020, outlining concerns on behalf of a group of staff at
Te Whare ō Matairangi (TWOM).

I would like to start by acknowledging these concerns and provide full assurance that we have taken
these concerns very seriously. I would also like to thank the team for their ongoing commitment and
hard work, despite the challenges faced.

We acknowledge that the last two years has seen an increase in the number of people requiring high
dependency care on admission, with little increase in bed availability. We have also seen a growing
number of presentations with complex drug and alcohol related mental health, housing and
community support issues.

This is a difficult reality that we all know impacts on staffing and service morale. Despite these
challenges, it is important that we remember to keep our clients and their whānau at the focus of our
care at all times.

This response will seek to address the concerns you have raised on behalf of staff and identify the
corrective measures that have been implemented since July 2019.

Increase of people admitted informally, with significant forensic history

Based on anecdotal information and staff observation, there has been a recent increase in the
admission of clients with offending histories. In response to this, we have required more staffing,
security and support from Te Korowai Whāriki (the Forensic Service) and Corrections.

While this increase has been observed, we are unable to quantify whether the increase is significant,
as data on offending history is not currently captured. This has been discussed with the MHAIDS ICT
Business Analysis team, to see how we can better understand the nature of these admissions.

When a person is assessed as requiring treatment in hospital, we need to understand whether there
is a willingness to engage in treatment. Where a person accepts that treatment is required and is
receiving this treatment in hospital, we should attempt to work with the person in the least restrictive
way. Once in hospital, if the person decides they want to leave, the inpatient team must consider the
use of compulsory treatment, if they are concerned about the risk posed by the patient leaving. The

Capital & Coast DHB | Private Bag 7902, Newtown, Wellington 6242
Wellington Regional Hospital, Riddiford Street, Newtown, Wellington 6021
www.ccdhb.org.nz | Phone: 04 385 5999 | Fax: 04 385 5856
Mental Health (Compulsory Assessment and Treatment) Act 1992 was enacted to protect people
requiring treatment, as well as to protect the community when there is a lack of capacity in recognising
the need for treatment.

Current actions

 We are currently reviewing the way data is collected about offending history. Discussions are
underway with the MHAIDS ICT Business Analysis Data team.
 We welcome your input into this process and would be happy to meet to discuss this further.

Assaults on staff and other clients

Our obligations under the Privacy Act and the Health Information Privacy Code mean we are not able
to comment on individual cases as described in your letter. However, MHAIDS is actively working
through challenges relating to violence and abuse from the public, and we recognise that the safety
of our staff is paramount. Since the event in July last year, steps have been taken to mitigate further
assaults, and both Capital & Coast District Health Board Health and Safety Service and WorkSafe were
advised.

Current actions

 We have received agreement from Te Korowai Whāriki to review and support when people’s
risk and behaviours require additional support beyond what an inpatient unit can offer. We
recommend that our staff contact the Forensic Service when further management and
support is required.

 This year we have reviewed all staff engagement in the Safe Practice Effective Communication
course (SPEC, previously known as Calming and Restraint). We have ensured all staff’s
education and training is current and up to date. Communication has occurred with New
Zealand Police and we now have training in SPEC regarding the language we use to get
emergency assistance.

 A discussion in Intensive Recovery Service (IRS) clinical governance was held last month to
consider options to improve engagement and treatment in the justice system for those
needing treatment whilst in the prison system. Dr Michael Doran, Acting Clinical Leader for
IRS, is liaising with Corrections and Forensic Service to look at solutions to improve access to
treatment in order to reduce the need for admission.

 We have worked with a security company, RECON, to provide security for daily 12-hour shifts.
There is an option to increase this security if risks increase on the unit.
Length of patient stays

The above chart shows the average number of bed days per patient. Some delays occasionally occur
dependent on complexity and individual needs. We acknowledge that housing and complex care
needs cause delays in discharge. Work streams such as the Acute Care Continuum group based at Hutt
Valley DHB, are looking at current and projected resource needs across the wider sector, and are
actively working with NGO providers to develop services that meet the needs of the people in our
care.

The Intensive Recovery and Adult Community Mental Health sectors are engaged with Aro Mai,
Housing First Collaboration in Wellington to help with finding sustainable housing and wrap-around
services.

We have weekly discussions with the rehabilitation service requesting timelines for transfer, and they
provide us with updates about clients they are trying to discharge to the community. Some of these
would-be discharges have been unsuccessful, which has slowed the transfer to rehabilitation. The
service is currently exploring how to improve supported accommodation resources to better support
these discharges from the rehabilitation service.

Current actions

 Noel Hensman from Strategy, Innovation and Performance (SIP, previously known as Planning
and Funding) is actively involved in reviewing these services and supporting these challenges
with our NASC team.
 Chris Nolan from SIP is leading the Acute Care Continuum group in Hutt Valley. He is actively
liaising with NGO providers to look at how we can develop new beds to safely manage people
with complex needs to support them more assertively in the community, possibly reducing
the need for an inpatient admission.

Best practice for patients with Borderline Personality Disorder (BPD)

Whilst admissions for people with known BPD should be brief, in some cases community treatment
and placement plans need to be developed. In such circumstances, the risk of suicide is unacceptably
increased if inpatient care is terminated before these due diligence steps are progressed.
Clinical decisions and practices are based on an individual’s needs and risks – not on a diagnosis such
as BPD. Once we understand the nature of someone’s situation, steps to mitigate risk can be taken to
safely support a person to manage potential harm in the community, but we must ensure plans are
developed and conversations are had prior to making such decisions.

Loss of experienced staff

The above data shows the vacancies within TWOM. All teams experience turnover. We support
employees to provide feedback and attend exit interviews to discuss reasons for leaving, as there are
various reasons for why staff leave roles. The turnover in TWOM is reasonably low; however, it is
unfortunate that in the last 12 months two of the social workers and psychologists have moved on,
and we have had few applicants to replace these vacancies.

Current actions

 We are actively trying to recruit to these vacancies and interviews are now underway. We
hope to fill most of roles over the next few months. In the interim we do have support from
social work in the CMHT and CRS.

Overcrowding in de-escalation and other areas

MHAIDS is experiencing an increase in individuals requiring a high dependency bed on admission.

Due to the complex nature of these presentations, we are often in a difficult position of determining
whether an acutely unwell person can be cared for in the community, or whether they require care in
an inpatient setting. Often the community setting is not appropriate for acute presentations, and as
a result, we are faced with high occupancy. We are working through data on admission type to
understand the resources we need moving forward.

Please see the data below. The data in February-March 2019 and September 2019 are doubled up due
to moving from one unit to another at the time of a fire – it does not reflect an increase in admissions
at that time.
Inadequate/safe staffing

In the last 12 months we have aimed to move to a variance response model that focuses on acuity of
need rather than nurse-to-client ratio. A TrendCare coordinator is working with the team to
authenticate the information in TrendCare, which in turn will provide a better understanding of
staffing need.

We have active advertising for all vacancies. As of last week, a senior social worker from the Crisis
Resolution Service has agreed to work full-time on the unit for the next month, whilst we progress
interviews. We have now interviewed an applicant for this role and we hope to fill this gap soon.

We have also reviewed the written roster for sick leave over the last three months; we note that over
half of the nursing and Mental Health Support Workers team are taking sick leave on a monthly basis.
There are currently 70-80 days of sick leave per month from these staffing groups. These sick days are
considerably higher over the weekend, with up to four staffing gaps per weekend day. In addition, we
have several employees on ACC and return to work plans.
The current roster requests and individual agreements do not give the organisation flexibility to deliver
the staffing need. The current roster faces two main issues: overstaffing on weekdays, and
understaffing on weekends. When we include sick leave on a weekend, we have recognised the
inability to cover the gaps.

We acknowledge that the 5:2 roster model needs reviewing to fit the current need of the unit, the
TrendCare roster model and employees’ leave requests. Arriving at a solution will involve extensive
consultation with unions and staff.

TrendCare is an international tool now being used nationally and supported by the Ministry of Health
to calculate the number of hours required to nurse each client on every shift. Once actualised, this
information should give us information regarding staffing needs 24 hours ahead of time.

When we are advised of short staffing by the team, the resource being requested is not reflected in
the number of hours captured in TrendCare. The team has reported that the current hours of care
reflected in TrendCare do not take into account the complexity of the environment observation
requirements and staffing required for the Dedicated Service Unit.

It is our view that, rather than inadequate staffing numbers, each of the components outlined above
are adding significant stress to the system and are putting pressure on the staff team. However, we
acknowledge that staff vacancies do need to be addressed, and recruitment is actively underway.

Current actions

 As part of the overall improvement plan, we have spoken to Danie Ralph, the Project
Coordinator for TrendCare in MHAIDS. She will look at whether additional measures can be
added into TrendCare to give more accurate staffing numbers based on the unit layout. There
is already a TrendCare improvement plan in place for TWOM as requested by the wider CCDM
management group.

 Since February 2019, the MHAIDS Operations Centre has implemented a number of initiatives
designed to assist the entire acute sector, including TWOM, with management of demand.
The MHAIDS Casual Pool Coordinator, along with the CNS for the MHAIDS Operations Centre
and Operations Centre Coordinator, has actively prioritised recruitment of casual pool staff
for the IRS. We have identified at least 10 casual pool positions for IRS; and we are continually
on boarding staff to this sector.

 We understand that casual employees are not a solution to permanent vacancy management,
however the service is committed to being flexible at times of high acuity. Casual pool use is
one option while we continue to recruit to permanent positions, and this remains a priority.

 The MHAIDS Duty Managers also work closely with the MHAIDS Casual Pool Coordinator, and
can allocate staff to acute areas in times of increased demand. An example of this occurred a
few weeks ago, when staff at TWOM asked for three mental health support workers to assist
with an admission; the MHAIDS Duty Manager on shift successfully arranged this.

 The MHAIDS Operations Centre also has a number of screens and electronic whiteboards
which monitor the flow through the service, including people waiting for an acute resource in
Emergency Departments. There are also hour-long 10:30 and 16:30 service handovers which
all key parties are expected to attend. Any increasing service acuity is identified in these
handovers, along with any resource gaps.
  An MHAIDS escalation, variance response and bed management protocol is being written by
the Interim Operations Manager, MHAIDS Operations Centre, and it is hoped that this will be
implemented by the end of 2020 in partnership with the unions. This is a very large piece of
work that will require extensive consultation.
 MHAIDS is in the very beginning stages of implementing a centralised rostering/workforce
coordination model within the MHAIDS Operations Centre. All rosters will be centrally
managed, and the aim is to achieve improved 24-hour oversight of staffing needs across
MHAIDS.

Change of purpose of Manaaki

We have fewer acute beds in Wellington per population, so we have discussed potential options to
redevelop our current resources to manage the immediate need. Increasing the number of beds in
Manaaki was an option discussed, however this has not been progressed due to staffing and layout
requirements. This could be revisited in future if staff wish to discuss further.

Current actions

 The MHAIDS General Manager led a steering group before Christmas to discuss gaps and
resources needed for TWOM. We have organised some work groups to understand where
these resources are needed and will continue to work on options.

Conclusion/Next steps

 We would like the support of PSA and its members in addressing rostering, sick leave,
overtime, and safe staffing issues, as well as support in developing a process for managing the
unit when short-staffed.

 We need an agreed understanding of safe staffing for the unit.

 We need to improve the information in TrendCare by adopting this practice as business as

usual. For us to understand the current and future FTE calculations for the unit, we require at
least 12 months of accurate information in TrendCare.

 We would like PSA’s input in exploring a different roster model to provide the coverage
needed across seven days.

 We agree with the recommendation in the letter regarding RECON security use, and would
like to explore this further with staff.

Please contact me if you wish to arrange a meeting to discuss any of these issues further.

Yours sincerely

Nigel Fairley
General Manger
Mental Health Addictions and Intellectual Disability Service