Autism and environmental adaptations within inpatient mental health units

The neurodevelopmental service was funded from NHS England to provide autism training to urgent and acute services in the Trust.

As part of this we also delivered a project to focus on the environments patients are seen in as the sensory environment is known to be a significant trigger for distress for some autistic individuals.

The project was running at the same time that a new 'sanctuary style' 23 hour clinical decision unit was being set up, called The Haven, so we were able to work closely with the project manager to influence some of the internal design decisions and were also able to offer some training to staff before the service began.

The aim of this unit is to prevent A&E admissions when people are in mental health crisis, as attendance at A&E has been proven to exacerbate mental health difficulties due to the chaotic environment. People with autism in particular struggle when they are both in a crisis and in a chaotic environment, thereby rendering A&E a last resort which means many people with autism suffer in silence.

We looked at the autism-friendliness of the wards and units. We used the environment assessment tool endorsed by NICE for CG142 when working with people with autism, which we adapted locally for the project.

The recommendations are based on informal observations in addition to the use of the tool. The team spent approximately half a day with ward managers and staff in each location. One day each was allocated to Brighton and the West as the environments were bigger and more complex than in other areas. An expert by experience (or EBE) who has a diagnosis of autism was included as part of the project and the results written up in co-production with her.

Firstly, we re-worked the environment tool endorsed by NICE. We did so by researching other tools, trialling their use and making it more specific using colour coding to facilitate quick win recommendations that we could hand out on the spot. It also made it easier to transfer the information to a spreadsheet and track trends.

It was difficult to engage busy ward managers at first and unfortunately our project dove-tailed with the end of a different project using urgent care lounges for the same purpose as The Haven. We implemented information sessions and flyers with heads of departments to get our foot in the door and soon enough people were on board with autism awareness-raising then with looking at the environment in acute settings. We did not go over budget. It was a case of engaging key people in the right way.

It was apparent that all of the wards and units were very keen on more autism training and awareness. There were no effective and consistent measures in place to screen people upon admission, and to not depend upon a ‘hunch’ that someone may be on the spectrum. Women in particular are very good at masking and may not present with the classic symptoms of being on the spectrum.

One of the team was on the autistic spectrum, none of the members of staff on the units visited noticed this. This illustrates how easy it can be to miss someone on the autistic spectrum.

Automatic screening is likely to pick up those people who need to be referred for formal diagnosis. Automatic screening will also enable specific measures to be put into place to support people on the autistic spectrum. It will also allow for data collection to enable subsequent analysis of the number of people on the autistic spectrum who access SPFT acute wards. It will also help to enable monitoring of vitamin D deficiency (and supplementing if necessary), which has a known link with autism.

There was a degree in variation of estimation of the number of people on the autistic spectrum on wards. For example some staff claimed they only have a few people on the spectrum in their care, others said most of their clients were on the spectrum. Neither of these wards mentioned actively screened for autism spectrum conditions. This is perhaps indicative of the fact referral for diagnosis is potentially still done on a ‘hunch’. There may also be a lack of awareness about how to refer for autism assessment to the Trust’s Neurodevelopmental Service and how to request expedition for inpatients.

In general the settings were found to have lots of scope for improvement in autism friendliness. They were generally noisy environments with no control over light levels, sudden loud sounds (doors), overwhelming smells, no escape opportunities (‘quiet’ rooms or sensory rooms). Quiet rooms that were available did not have sound-proofing (apart from one) and few had environmental controls in place for altering artificial lighting or sunlight.

Each setting was given a report with recommendations and suggestions of what they could do to improve their environment, including the addition of specified sensory items they could purchase, which could be used for individual care plans (as calming measures/anxiety management tools).

We identified the need for autism awareness, screening and training and it would be great to encourage individual wards to implement autism-friendly improvements as part of a QI project (one ward was already doing this to create a sensory room).

It would also be good to include autism awareness and best practice in the on-going quality and safety reviews as a means of both raising awareness, auditing current practice and monitoring improvements in practice over time.

See attached file for the full list of recommendations.