Creating therapeutic acute care environments

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By Paul Rooney, Joint National Lead CSIP/NIMHE Acute Care Programme


When I was asked to write a piece on what is important in designing good acute care environments for mental health services, I started by listing some of the traditional key components; the ward, day unit, team base, etc. But, despite the need to re-define what we mean by such terms as the ‘ward’, in a twenty-first century service, I felt there was something missing with this approach. I realised that, rather than starting with what is needed for those who are mentally unwell, we need to start with – and keep to the forefront of planning – those things which would be key requirements for any of us, if we had to stay away from home.

Most of us have a pretty clear idea of the essential requirements, because we stay in hotels! Thinking about the key attributes of a good hotel is a good starting point to designing and facilitating a good psychiatric unit.

These include:

  • Being easy to get to
  • A welcoming and informative reception
  • Feeling my possessions and I are safe and secure
  • Being warm, clean and bright
  • Respect for my privacy and dignity
  • An uninterrupted night’s sleep
  • My own bedroom with decent
  • bathroom /shower
  • Food and drink availability
  • Friendly and attentive staff


There are, of course, some key differences between a hotel and an acute mental health unit. Acute mental health buildings need to be both containing and therapeutic. You are not confined to the hotel, nor do you feel stigmatised by having stayed in a hotel. But these are not reasons why any of the above should be compromised.

Indeed, they make paying close attention to these aspects more not less important. Yet somehow, despite investing more than is usually spent on the equivalent sized hotel we, too often, fail to achieve or protect these crucial elements in a number of our psychiatric units. In part this is because we sometimes let other considerations override these basic essentials either at the commissioning stage or when the building is in use.

The CSIP National Acute Care Programme has worked with Department of Health Estates and Facilities to produce guidance on the planning and commissioning of new acute mental health services and accommodation. A workbook to inform and assist local services ‘Laying The Foundations’ is available here. This work highlighted that, in addition to ‘good hotel’ features, issues of social inclusion, engagement and integrated working are key to effective service delivery and that we need to be designing or re-organising our mental health buildings to enhance these aspects.


Social inclusion and stigma

Our buildings are the biggest and most powerful advertising hoardings we have to convey positive (or reinforce negative) messages about mental health. It is when people are admitted as inpatients that their social inclusion (jobs, tenancies, education….) can be most at risk. More attention needs to be given to design and service arrangements that actively assist inclusion and community engagement and to address rather than avoid issues of ‘nimbyism’. Developments should be used as a positive catalyst for engaging the local community and addressing stigma. Mental health units need to be outward looking and be designed to consciously build positive working relationships with the community served. Build for practical partnership working. Invite the community in. Your local community are also your customers and potential allies.

The redevelopment of many of the large old mental illness hospital sites gives a useful insight into the ill-informed nature of most objections to nearly all proposals to site mental health facilities in local communities. When the mental health facilities are there first, there is no shortage of developers wanting to acquire adjoining sites for housing and no shortage of buyers for the houses. If the housing was there first, the same people would object to the mental health development.



As Star Wards has so successfully championed, acute inpatient provision needs to be designed to maximise the opportunity for therapeutic engagement and to protect service users’ support networks and community connections. ‘Boredom and lack of anything to do’ is an oft-cited complaint about inpatient care by service users; the consequences of which include untoward incidents and impeded recovery. Adult acute inpatient units need to include multi-purpose large and small group activity spaces that can accommodate a varied timetable of therapeutic and recreational activities, including evenings and weekend activities with opportunities for activities to take place both on and off the ward. Particular attention needs to be paid to ensuring good access to and the design of gardens and outdoor spaces.

In addition to the implications for size and location of services, providing accommodation for evening and weekend activities and encouraging community in-reach suggests a need to rethink such traditional acute unit accommodation as the ‘day hospital’ and the ‘occupational therapy department’ towards development of more flexible activity provision that can be a catalyst for community use and partnerships. I would favour the provision of an activity centre (readily accessible from the ward) that operates in the day, in the evenings and at weekends. With sensible scheduling of key staff such as OTs, alliances can usefully be developed with local community organisations to help provide activities at these ‘out of office hours’ times. Such arrangements would reduce the potential for untoward incidents and provide stepping stones for service user reintegration when discharged from acute care.


Integrated working

In the same way that it is important to ensure the mental health unit is not isolated from the community it serves, it is important that inpatient services are not detached from the rest of the mental health system. Where this happens it amounts to a sort of ‘system exclusion’ based on outmoded notions that fail to recognise that the inpatient unit is as much an integral part of any modern mental health service as the new range of ‘community’ services.

Particular attention needs to be paid to the interdependency of acute inpatient and crisis resolution home treatment services (CRHT) to ensure continuity of care, admissions are appropriate, discharges are not delayed and care planning is fully informed. As the National Audit Office report on ‘The Role of Crisis Resolution Home Treatment Services’ recommends there is a need to maximise effective collaboration and communication between inpatient services and CRHT service and that this is best facilitated by co-locating these services together on the same site where possible. Within existing services consideration should be given to how closely integrated working between CRHT and inpatient services might be enhanced by co-location.


Reviewing your provision

Ask yourself (or your Acute Care Forum) are we using our facilities to best effect? Are current building use arrangements primarily driven by staff or service user/carer concerns? When did we last review them together? How could they be improved?

While well designed and spacious buildings play a key part in facilitating a therapeutic environment, buildings are tools that in the end depend on the skills, attitudes and operational arrangements of those using them. To get the best from our buildings we need skilled staff, involvement of all the stakeholders and constant review that these tools are being put to best use in changing times.

When reviewing the use of your existing accommodation, or developing a brief for new accommodation, it is very important to spend enough time getting it right and gaining ownership by all those who will use and influence the use of the building – service users, carers, clinical and ancillary staff, neighbours and local community organisations. In many instances design briefs are strong on generalities such as the need for a ‘domestic, therapeutic milieu’ without any explanation about how this is going to be achieved in practice. There is a need to focus on how the buildings are really going to be used. This can be assisted by stakeholders analysing some of the key ‘events’ to see how current arrangements might be improved such as:

  • An admission – from leaving home to admission to the ward
  • A day on the ward – including evenings and weekends
  • Routines such as meal times, dispensing
  • medication and ward rounds
  • Discharge home and follow up
  • Inter team working and communication arrangements

And here is one made earlier….

As Star Wards has highlighted, contrary to popular misconception, there is a lot of excellent practice and some very good acute care environments being developed. Common features of some of the best of the new units (such as those in Lowestoft, Worthing and Hartlepool) seem to include that they are small, local and have well integrated service arrangements.

Tees, Esk and Wear Valleys NHS Trust’s Sandwell Park unit in Hartlepool has rightly been a Star Wards best practice exemplar. One of the key lessons to be learnt from this service is not just the finished product but the process undertaken to create it. It is an outstanding example of how high levels of involvement help develop meaning in and ownership of a building by those who use it. Workshops were held with a wide range of staff, service users and carers to contribute to the design process and directly influence the proposed new facilities. One of these workshops identified a’ Top 10’ aspirations for the new unit.

These were:

  1. Multi-functional rooms/availability
  2. Flexibility of recreation rooms and choice of activities
  3. Single-sex, en-suite bedrooms
  4. More use of natural light
  5. Better garden areas
  6. Artwork including space to exhibit user/carer works
  7. Information areas
  8. Good access and secure parking
  9. Clear welcoming reception area
  10. Café area /24 hr beverage availability.


As suggested at the beginning of this piece, not that different from the equivalent key features for a hotel!


This article was first published in ‘Star Wards – Second edition’ 2008

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