Thomas Embling Hospital expansion: Co-design and engagement report

The Thomas Embling Hospital expansion project is the first stage of a major rebuild which will fulfill a key recommendation of the Royal Commission into Victoria’s Mental Health System.

The Royal Commission was established in February 2019 after the Victorian Government recognised the system was failing to support people living with mental illness or psychological distress, their families, carers,and supporters, and those working in the system.

The final report made specific infrastructure recommendations regarding the expansion of forensic mental health beds at Thomas Embling Hospital in Fairfield.

In response, the Victorian Budget 2021-22 allocated $3.8 billion to supporting mental health projects and initiatives around the State including $349.6 million towards the stage 1 expansion of Thomas Embling Hospital. An additional $123.9 million was also announced in the 2022-23 State Budget for the next stage of redevelopment of the Thomas Embling Hospital.

The Royal Commission report also found the perspectives and experiences of people with lived experience of mental illness or psychological distress are often overlooked when new mental health facilities are being designed.

Power imbalances throughout the system mean that the experiences, perspectives, and expertise of people living with mental illness or psychological distress, their families, carers,and supporters, and those working in the system are often not valued or recognised.

To this end, the Royal Commission also recommended that these people be involved in meaningfully co-designing future mental health facilities.

The Thomas Embling Hospital expansion project team has committed to implementing these recommendations by ensuring co-design is a key and embedded component of this project, and places lived experience at its heart.

'Being a consumer, there are things that I see that staff may not. I understand what it is like living in these units. There are things about my experience there that I really want to change.'
- Thomas Embling Hospital Consumer Representative

Thomas Embling Hospital is a secure forensic mental health hospital, providing care and treatment for people living with a serious mental illness in, or at risk of entering, the justice system.

The stage 1 expansion project will deliver an additional 82 secure mental health beds – including a new dedicated 34-bed women’s precinct, a 48-bed medium security men’s facility and clinical administration facilities.

This project is being delivered by the VHBA in partnership with Forensicare, the state-wide specialist provider of forensic mental health services in Victoria.

Construction on the first stage of the expansion project is commencing in 2022 and main works are due for completion in mid-2024.

'Nobody is more aware of what we need in this hospital more than the people who have the lived experience of having been treated.'
- Executive Director Redevelopment & Asset Management, Forensicare

The objective of the project team was to develop and embed a structured and comprehensive co-design and engagement process that would achieve meaningful consumer and service outcomes for the Thomas Embling Hospital expansion project.

This process was designed to ensure consumers, carers, families and staff with lived experience of mental ill-health, and in particular the specialist services provided by Forensicare, are at the centre of the planning and design.

The principles from Forensicare’s Co-design Framework have been applied to this process. These principles are consistent with the Department of Health’s Mental Health Lived Experience Engagement Framework and outline a commitment to be purposeful, prepared, genuine, inclusive and to communicate clearly.

This report encompasses all co-design and engagement activity that took place to inform the planning and design of stage 1 of Thomas Embling Hospital expansion project from 2020 to September 2022. It does not cover co-design activity that took place to inform broader topics, such as workforce planning.

People with lived experience of mental ill-health have been involved in every aspect of and facility design of the upgraded Thomas Embling Hospital, as appropriate for a forensic mental health facility.

This means they have helped shape every area of the facility that they will be spending time in. The decision to not include consumers in unnecessary workshops, and those that weren’t appropriate from a safety point of view, was made to ensure they were not too overtaxed by an excessive workload and could stay engaged on areas they could influence.

'For us to have people with lived experience actively involved in every user session that involved consumer spaces is just fantastic. It has enabled us to have a lot more confidence that what we are delivering will meet the needs of consumers and be adaptable into the future as these needs change.'
- Director, Guymer Bailey Architects

The RACC was established to guide and oversee the co-design approach for the project and ensure engagement with consumers, carers, external lived experience experts and senior management from Thomas Embling Hospital.

The RACC was set up through an expression of interest process and included past and current consumers and carers, staff and project representatives from both VHBA and Forensicare. For a meeting to go ahead – at least half of the committee members were required, and fifty per cent of hospital or community consumers, and fifty per cent of carers needed to be in attendance.

The committee met from September 2021 until September 2022.

Meetings were held monthly online (due to COVID-19 restrictions) and ran for approximately 90 minutes, with opportunities for smaller group discussions to facilitate a safer space for many consumers, leading to a more in-depth sharing experience.

While consumer perspective is invaluable, decisions relating directly to the safety and security of the hospital and consumer wellbeing can feel confronting and intense. Challenging topics were discussed openly with the committee to formalise if they are comfortable to move forwards with the topic or not. The last 15 minutes of each meeting was scheduled for committee members to raise any issues that they were not comfortable discussing or language they found distressing. Debriefing opportunities for consumers and carers are provided before, after and between meetings.

Many of committee members with lived experience spoke of how inclusive the committee was. Despite some challenges with the process, they shared how much they valued the opportunity to be heard, as well as the confidence and sense of purpose the experience provided.

'[The committee] felt like a very safe space. There were [some difficult topics] that we had to comment on, and I felt that it was a safe environment to share my views. In different forums, I may have not said anything but in this environment, I felt really comfortable to have my say.'
- Thomas Embling Hospital Consumer Representative

Consumers with lived experience were invited to attend most project working groups to provide input into elements of the design development for:

• the men’s precinct and the women’s precinct
• de-escalation and seclusion
• interior design
• dining rooms and model of food service
• environmentally sustainable design alignment
• IT and AV systems
• design principles.

Consumers were supported by the Forensicare Co-design Lead to prepare for these meetings and were offered debriefing afterwards if required.

Maintaining continuity of attendance at meetings was important and consumer representatives were reimbursed accordingly for their time, as many felt it helped them feel valued.

The CAG is a forum for Thomas Embling Hospital patients to engage and consult with staff about improving service quality and delivery. As a key consumer group at the hospital, the project team have engaged with the CAG at key stages of project to present and obtain feedback.

In May 2022, the Project Manager – Clinical Lead and the Co-design Lead embarked on attending each unit at the hospital to speak with consumers at their Consumer Community Meetings and at the Best Care Staff meetings. This was to ensure that each consumer and staff member had a strong understanding of the project and to encourage feedback and ideas.

The FCAG (formerly known as the Family Sensitive Practice Committee), is a forum for families and carers of Forensicare consumers looking to engage and improve service quality and delivery particularly regarding carer experience.

Like the CAG, the project team engaged with this group to present and obtain feedback about the project. Feedback captured at these sessions explored areas of importance to families and carers, such as the entrance and arrival experience to the hospital, reception, security, gatehouse, the entrance to the units and visitor’s rooms.

When design entered design development phase, physical prototypes (made of foam) of the bedrooms, the seclusion suite and enhanced care suite and a full-size projection of the floor plan were created so users could experience the space and provide feedback.

The Co-design Lead walked around the layout with the consumers, testing the spatial practicality of the design and gathering feedback to take back to the project team.

Staff, project stakeholders and executives also had the opportunity to experience the space and provide feedback.

The Wurundjeri Land Council is a Registered Aboriginal Party (RAP) for a large area in and around Melbourne.

The project presented to the council and established an ongoing engagement meeting once a month from November 2021 to September 2022, to work through key aspects of the project.

Forensicare aims to work in partnership with the Wurundjeri Land Council, to ensure that the importance of the Yarra River and Merri Creek, both close to the location of the Hospital, is recognised. Forensicare requires First Nations People’s advice to confirm that this project remains culturally appropriate for consumers.

Forensicare established a First Nations Advisory Committee to strengthen its delivery of best practice forensic mental health services for First Peoples and enhance the representation and engagement of First Nations mental health professionals in the field. A first nations consumer also had specific input in the project.

The Priority Communities Advisory Group was established to strengthen Forensicare’s delivery of best practice forensic mental health services that respond to the needs of priority communities. These include culturally diverse communities, LGBTIQA+ communities, the ageing, people with a disability and women.

Feedback was actively sought from consumers and carers who had areas of concern and issues they felt strongly about.

On the ground engagement with staff has been completed in workshops, informally and formally in a variety of meetings and manners. At the hospital, if a staff member has a point to raise, they will raise it. They are aware that in a forensic mental health hospital, no point is too small or objective too large to raise.

The safety and security of all staff (as well as consumers and carers) is of paramount importance in the design and use of the two new precincts. Staff feedback and the volunteering of information has been and will continue to be, an invaluable source of information. Staff feedback can also include consumer insights. For this reason, future consultation with staff will encourage feedback that considers the provision of space and services for staff themselves, as well as consumers.

A number of individually tailored workshops and briefings took place with key stakeholder groups, including neighbouring organisations, relevant government departments and other interested parties to ensure a wide range of views and experiences were represented.

The purpose of these sessions was to provide an overview of the project, to identify their needs and understand any key issues and challenges that should be considered.

The Thomas Embling Hospital Expansion Project Executive Committee and Forensic Mental Health Steering Committee have overseen project planning and implementation from its earliest stages, including being assured that co-design is being actively and appropriately practiced.

'The process has always been about making sure the broadest range of voices is heard and responded to. If we get stuck on a point, we will reach out and talk to other services nationally and internationally to learn what their approach and their experience has been.'
-  Principal Advisor Design – Special Projects, Health Infrastructure

What we heard

• The existing women’s unit (a combination of acute and sub-acute) can impact on the progression of women through the recovery journey.
• The provision of a separate women’s precinct is highly valued from a safety and privacy perspective.
• Care for women is more appropriate in a dedicated environment, where it can be tailored to better support women’s needs.

'Being a consumer and having gone through the system myself, (I saw) women really struggle because they’re either well, or unwell – there’s no in-between. The new women’s precinct will be so helpful to help people recover – it can help women to visualize the journey (to recovery).'
- Thomas Embling Hospital Consumer Representative

What we’re doing

• The upgraded hospital will include a new dedicated 34-bed women’s precinct.
• The new women’s precinct will have three distinct levels of acuity; acute, sub-acute and rehabilitation.
• This new precinct will support the entire recovery journey. It will enable care to be tailored to individuals depending on where they are at in their recovery, ensuring we are not compromising safety and security. It will also provide opportunities for those further along the recovery journey to access greater freedoms.

'(We have not designed a women’s facility) of this type before, so we are exploring the things consumers have told us they really want in the design to make it truly feel like their space.'
- Principal Advisor Design – Special Projects, Health Infrastructure

What we heard

• More green space and a greater connection to outdoors is important for recovery. This includes access to landscape, both inside and outside, as well as the freedom to move around the hospital site (when appropriate), and the feeling of being immersed in green spaces.
• The opportunity to participate in horticultural activities is highly valued.
• Space and different types of areas for relaxation and exercise is important.

What we’re doing

• The designs maximise garden areas and green space – with landscaped courtyards and winter gardens that consumers have access to on every level. There is a private garden on ground level in the women’s building, and the men’s garden has been extended.
• There will be large open space to exercise, more access to sunshine and fresh air, a yarning pit and an edible rooftop garden which consumers can tend to.
• The design also maximises the serene views of the surrounding parklands and river.

'In the designs, we have treated access to the outdoor space and landscape as a key part of the therapeutic environment. It is equally as important as internal space.'
- Principal Advisor Design – Special Projects, Health Infrastructure

What we heard

• ‘Normalising’ daily tasks is a high priority for consumers. This ranges from meal preparation to doing their own laundry. For example, large accessible kitchens make it easier for consumers to plan and prepare their own meals, while dining rooms provide opportunities to socialise and gather.
• Space and activities for recreation and socialising is valued.

What we’re doing

• The layout of the new buildings ensures there is adequate space for daily living activities, where possible, across the care continuum.
• Large functional kitchens have been incorporated into the plans, with significant input from consumers, about how these spaces can operate in a safe way.
• Each floor level is provided with a consumer laundry, another opportunity to encourage consumers to develop skills necessary for when they leave the hospital. On Level 3 of the women’s precinct , a laundry is provided in each apartment, to further support women preparing to transition to independent, living in the community.
• In addition to the existing gym on the hospital campus, each level in the new buildings has a small gym so consumers can incorporate exercise into their daily routine. Activity courtyards are also on every level.
• All units have community activity spaces.

What we heard

• Privacy in each unit is a priority. For example, consumers suggested locating shared spaces close to the entrance, and more private spaces further away.

What we’re doing

• This theme has been incorporated where possible in the architectural design of the buildings and in the layout of the facility.
• Consumer bedrooms will be in a bedroom wing, located off the main living areas, providing more privacy with a more domestic approach to the layout.
• Shared spaces will also be located adjacent to the staff and supported station, allowing consumers to feel comfortable with staff around.

What we heard

• It is important for physical spaces to look and feel different as people move through the recovery journey.
• A less clinical feel, as people move further along the recovery journey, can help consumers adjust to life as it would be in the community.

'Different colours could be used in different rooms to help people relax.'
- Thomas Embling Hospital Consumer Representative

What we’re doing

• This theme has influenced the architectural design and fit out of the buildings, and the layout of the facility.
• Finishes will vary as consumers make their way up the building through recovery – with more colour and texture introduced to reflect their progress.
• Furniture will change as the level of security decreases – from robust furniture and fixed tables for those most unwell, moving to more domestic style furniture as consumers move along the recovery path.

What we heard

• The design of therapeutic sensory spaces is important and should be designed as a consumer-led process.

What we’re doing

• The design incorporates multiple spaces where consumers can learn techniques to manage stress and regulate their own behaviour.
• The new facilities will include dedicated sensory rooms, that facilitate positive and calming sensory experiences such as music, lighting, weighted geckos, tactile games, and so on.
• For more challenging times of behaviour management, there is also a dedicated de-escalation room that has a rubberised softer floor, fixed bench seats and bean bags. It is designed to minimise accidental harm to those consumers in a heightened state of agitation.

What we heard

• Adequate space is important in busy areas. Crowded areas, such as the dining room, can be quite noisy and stressful for consumers.
• Consumers highlighted the importance of creating an environment which enables the development of positive relationships, so consumers can support each other.
• Consumers also identified some residents may require separation from other cohorts (vulnerable groups) to help minimise any opportunities for predatory behaviours.

What we're doing

• The design will ensure acoustics are managed well, and that there is enough space in busy areas, such as the dining room.
• Colours, materials and finishes that are considered therapeutic have been chosen based on extensive research and consumer feedback.
• Each consumer accessible room that is a shared space is designed so consumers and staff have multiple exit paths if required.
• A variety of lounge types on the shared units have been included in the design. Large common lounges, mid-sized communal lounges, and smaller quiet lounges, provide choice for consumers.
• There is access to shared spaces on ground floor, including a multi-faith room, multi-purpose rooms and garden spaces that consumers from each floor level have varying access to, allowing consumers to meet and interact.
• The building supports options in clinical interventions, which will help Forensicare work towards the Royal Commission’s recommendation to reducing restrictive interventions.