National Audit of Dementia Care in General Hospitals … NAD Local Report 3.pdf · National Audit of Dementia Care in General Hospitals 2016-2017 Local report for: The Countess of

National Audit of Dementia

Care in General Hospitals 2016-2017

Local report for:

The Countess of Chester Hospital

Countess Of Chester Hospital NHS Foundation Trust

July 2017

Commissioned by:

Many thanks to Hwyl for permission to use the cover artwork. Hwyl is an art project run by Dementia Matters in Powys (DMiP) and Arts Alive Wales based at the Brecon War Memorial Hospital. The project focuses on working with elderly patients on hospital wards, with their families, carers, the ward staff and artists on a weekly basis.

With thanks to Rhiannon Davies (DMiP) and Tessa Waite (Arts Alive Wales). This audit was commissioned by the Healthcare Quality Improvement Partnership (HQIP). The report is produced and published by the Royal College of Psychiatrists’ Centre for Quality Improvement. © Healthcare Quality Improvement Partnership Ltd. (HQIP) 2017

Authors This report was prepared by Chloë Hood, Chloë Snowdon, Sarah Keane, Simone Jayakumar and Vicky Cartwright. Content is advised and approved by all members of the Steering Group. Please see full details of the Steering Group members and the Project Team below.

Steering Group Professor Peter Crome, Honorary Professor, UCL, Emeritus Professor, Keele University (Chair)

Professor Dawn Brooker, Director, University of Worcester Association for Dementia

Dr Amanda Buttery, Innovation Fellow Dementia, South London Academic Health Science Network

Angela Connelly, Carer Representative

Dr Oliver Corrado, Consultant Geriatrician and Leeds Teaching Hospitals' 'Dementia Champion’ (NAD

Clinical Lead)

Dr Duncan Forsyth, Consultant Geriatrician, Cambridge University Hospitals/ British Geriatrics Society

Dawne Garrett, Professional Lead for Older People and Dementia Care, Royal College of Nursing

Nicci Gerrard, Carer Representative, John’s Campaign

Professor Rowan Harwood, Professor of Geriatric Medicine, Nottingham University Hospitals

Janet Husk, Programme Manager, Healthcare of Older People, Clinical Effectiveness and Evaluation

Unit (CEEU), Royal College of Physicians

Kelly Kaye, Partnership Manager, Dementia Action Alliance

David McKinlay, Programme Manager, Healthcare Quality Improvement Partnership

Dr Wendy Neil, Consultant Psychiatrist, Faculty of Old Age Psychiatry, Royal College of Psychiatrists

Sean Page, Consultant Nurse – Dementia, Wrexham Maelor Hospital

Sue Pierlejewski, Carer Representative

Dr Imran Rafi, Chair of Clinical Innovation and Research, Royal College of General Practitioners

Léa Renoux, Senior Health Influencing Manager (Policy), Age UK

Dr Kevin Stewart, Clinical Director, Clinical Effectiveness and Evaluation Unit (CEEU), Royal College of

Physicians

Beth Swanson, Lead Nurse, The James Cook University Hospital (Nurse Consultant to the audit)

Gavin Terry, Policy Manager, Alzheimer's Society

Dr Daphne Wallace, Living with Dementia Group

Kirsten Windfuhr, Associate Director, Healthcare Quality Improvement Partnership

The National Audit of Dementia Project Team

Professor Mike Crawford, Director of the Royal College of Psychiatrists’ Centre for Quality

Improvement

Dr Alan Quirk, Senior Programme Manager (Research and Audit)

Chloë Hood, Programme Manager

Chloë Snowdon, Deputy Programme Manager

Sarah Keane, Project Worker

Simone Jayakumar, Project Worker

Vicky Cartwright, Project Administrator

Holly Robinson, Deputy Programme Manager (from 2015 to February 2016)

Rahena Khatun, Project Administrator (from 2015 to June 2016)

National Audit of Dementia Round 3 • The Countess of Chester Hospital | 1

Acknowledgements We would like to thank all members of hospital staff and carers of people with dementia who completed a staff or carer questionnaire during this round of the audit. Thanks also to Kelly Kaye at Dementia Action Alliance, Alzheimer’s Society Talking Point and Bethan Davies and Sarah Beardon of Imperial College, London. Huge thanks to staff at all of the feasibility and pilot study sites for their part in testing the tools and commenting on necessary amendments for audit proper. Special thanks to the audit leads: Louise Ayres, St Peter’s Ward, Hemel Hempstead Hospital, Hertfordshire Community NHS Trust Maggie Bean, Macmillan Wolds Unit, Bridlington and District Hospital, Humber NHS Foundation Trust Wendy Blank, Dartmouth and Kingswear Community Hospital, Torbay and Devon NHS Foundation Trust Joanne Burden, Withernsea Community Hospital, Humber NHS Foundation Trust Jacqui Bussin, St Helens Hospital, St Helens and Knowsley Hospitals NHS Trust Liz Champion, Tunbridge Wells Hospital, Maidstone and Tunbridge Wells NHS Trust Debra Dawson, Dawlish Community Hospital, Torbay and Devon NHS Foundation Trust Fiona Durham, Castleberg Hospital, Airedale NHS Foundation Trust Chris Dyer, Royal United Hospital Bath, Royal United Hospitals Bath NHS Foundation Trust Andrew Fletcher and Judith Gibson, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust Theresa Frang, Amersham Community Hospital, Buckinghamshire Healthcare NHS Trust Jenny Friend, Blyth Community Hospital, Northumbria Healthcare NHS Foundation Trust Lucy Frost, Zachary Merton Hospital and Uckfield Community Hospital, Sussex Community NHS

Foundation Trust Carla Howgate and Sue Johnson, Southport & Formby District General Hospital, Southport and Ormskirk

Hospital NHS Trust Nina Jalota and Teresa Keegal, Teddington Memorial Hospital, Hounslow and Richmond Community

Healthcare NHS Trust Claire Jones, East Riding Community Hospital, Humber NHS Foundation Trust Vicki Leah, University College Hospital, University College London Hospitals NHS Foundation Trust Chooi Lee, Kingston Hospital, Kingston Hospital NHS Foundation Trust Peter McCann, Chorley and South Ribble Hospital, Lancashire Teaching Hospitals NHS Foundation Trust Anya Pinhorn, Ystradgynlais Community Hospital, Powys Teaching Health Board Evelyn Prodger, Crawley Hospital, Sussex Community NHS Foundation Trust Sharon Savigar, Liskeard Community Hospital, Cornwall Partnership NHS Foundation Trust Roger Simpson, Ilkeston Community Hospital, Derbyshire Community Health Services NHS Foundation

Trust Inderpal Singh, Ysbyty Ystrad Fawr, Aneurin Bevan University Health Board Claire Smith, Lings Bar Hospital, Nottinghamshire Healthcare NHS Foundation Trust Beth Swanson, South Tees Hospitals NHS Foundation Trust Andrew Thomas, Bridgnorth Community Hospital and Whitchurch Community Hospital, Shropshire

Community Health NHS Trust Teresa Walls, Bluebird Lodge, Suffolk Community Healthcare, Ipswich Hospital NHS Trust Gill Withington, Warminster Hospital, Savernake Community Hospital and Chippenham Community

Hospital, Wiltshire Health and Care Sue Yorwerth and Anthony White, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board Lesley Young, Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust We would also like to thank all consultants and members of the Steering Group and our Chair, Peter Crome.


Table of Contents

Introduction .................................................................................................................................................................................................. 5

Mean average scores across England and Wales .......................................................................................................................... 9

The Countess of Chester Hospital scores ....................................................................................................................................... 10

Key findings in local and national reporting ................................................................................................................................. 11

Key findings from the National Report .................................................................................................................................. 11

Key findings and The Countess of Chester Hospital ........................................................................................................ 12

Audit Themes ............................................................................................................................................................................................. 22

Assessment ....................................................................................................................................................................................... 23

Information and Communication ............................................................................................................................................ 26

Staffing and Training .................................................................................................................................................................... 32

Nutrition ............................................................................................................................................................................................. 36

Discharge ........................................................................................................................................................................................... 40

Governance ....................................................................................................................................................................................... 46

Staff and carer comments, carer expectations and recommendations .............................................................................. 54

Staff suggestions for your hospital ......................................................................................................................................... 55

Carer comments for your hospital .......................................................................................................................................... 56

Carer expectations from the National Report .................................................................................................................... 57

Full list of recommendations from the National Report ................................................................................................. 59

List of web resources ............................................................................................................................................................................... 63


List of Figures and Tables

Figures

Figure 1: Percentage of patients who had an initial screening for delirium, a clinical assessment for delirium folowing the screening and symptoms of delirium summarised for discharge .............................................................. 12

Figure 2: Results from the ‘mini audit’, showing the percentage of patients checked who had a personal information document present ........................................................................................................................................................... 13

Figure 3: Percentage of casenotes where information about the person with dementia had been collected .. 14

Figure 4: Carers’ perspective on how well informed staff were about the needs of the person with dementia 15

Figure 5: Staff perspective on the availability of personal information to help them care for/ support people with dementia ............................................................................................................................................................................................ 15

Figure 6: Staff perspective on meeting the nutritional needs of patients with dementia ......................................... 16

Figure 7: Staff perspective on access to finger foods for people with dementia .......................................................... 17

Figure 8: Staff perspective on access to snacks for people with dementia ..................................................................... 17

Figure 9: Staff view of training provided by their current hospital ..................................................................................... 18

Figure 10: Staff perspective on support available from specialist dementia services during office hours ......... 19

Figure 11: Staff perspective on support available from specialist dementia services out of hours ....................... 19

Figure 12: Carer perspective on whether the person with dementia was treated with respect .............................. 20

Figure 13: Carer view of support provided to them by the hospital .................................................................................. 21

Figure 14: Carer overall view of patient care provided by the hospital ............................................................................ 21

Tables

Table 1: Explanation of how data tables are presented in audit theme chapters ........................................................... 8

Table 2: Range of scores in the national sample, broken down by quartile .................................................................... 10

Table 3: Your hospital’s scores and rankings ............................................................................................................................... 10

Table 4: Assessment score for your hospital ................................................................................................................................ 23

Table 5: Information and communication scores for your hospital .................................................................................... 26

Table 6: Nutrition score for your hospital ..................................................................................................................................... 36

Table 7: Discharge score for your hospital .................................................................................................................................... 40

Table 8: Governance score for your hospital ................................................................................................................................ 46


Introduction

Local reporting

This local report contains a full presentation of your results for the third round of the National Audit of Dementia alongside the national results from all participating hospitals. If your hospital participated in the second round, these results are also shown where applicable. The national data and data from your hospital are presented in four ways in this report: Themed scores derived from the four audit tools Key messages and recommendations from this round’s National Report A full breakdown of your data by audit theme A full breakdown of your data by audit tool (in separate Appendices document).

Background to the audit

The National Audit of Dementia (care in general hospitals) examines aspects of care received by people with dementia in general hospitals in England and Wales. The audit is commissioned by the Healthcare Quality Improvement Partnership on behalf of NHS England and the Welsh Government, as part of the National Clinical Audit Programme. The audit is managed by the Royal College of Psychiatrists in partnership with: Royal College of Nursing Royal College of Physicians British Geriatrics Society Alzheimer’s Society Dementia Action Alliance Age UK John’s Campaign.

Data collection There have been two previous rounds of the National Audit of Dementia, reporting in 2011 and 2013. Round 2 of the audit showed that while significant progress in the care provided to people with dementia had taken place, some aspects of care still needed to evolve. The Round 2 report recommended collecting feedback from the carers of people with dementia and staff who provide care, to gain a better understanding of important aspects of care, such as communication and understanding individual needs. Round 3 of the National Audit of Dementia collected data between April and November 2016. The audit was open to all general acute hospitals in England and Wales providing acute services on more than one ward which admit adults over the age of 65. One hundred and ninety-nine hospitals in England and Wales (98% of eligible hospitals) took part in this round of audit. A list of participating hospitals is on our website.


http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/nationalclinicalaudits/dementia/nationalauditofdementia.aspx�

Participating hospitals were asked to complete four elements for the audit: A hospital level organisational checklist A retrospective casenote audit with a target of a minimum of 50 sets of patient notes A survey of carer experience of quality of care A staff questionnaire on providing care and support to people with dementia.

In total, the audit received 199 organisational checklists, 10047 casenote submissions, 14416 staff questionnaires and 4664 carer questionnaires. Hospitals which submitted less than 5 carer or staff questionnaires, have not received any data in their local report in order to protect anonymity. Hospitals which submitted 5 to 9 of either questionnaire have not received the demographic information for that questionnaire. The Countess of Chester Hospital completed an organisational checklist, submitted 51 casenote audits, submitted 30 eligible staff questionnaires and 6 eligible carer questionnaires.

Audit standards The standards for the National Audit of Dementia have been derived from national and professional guidance, including NICE Quality Standards, the Dementia Friendly Hospitals Charter and reports from the Alzheimer’s Society, Age Concern and Royal Colleges. The standards have been compiled with their sources and the questions used to measure them, and can be found on the audit website.

How to use this report

Scoring in Round 3 of audit For the first time for the National Audit of Dementia, we present hospital level scores. The scoring system allows easy comparison between hospitals on the different themes of the audit. There are seven scores, each relating to an audit theme, plus a score for the carer overall rating of care. There was insufficient data available to produce a score for the staffing and training theme. The full method for the scoring can be found on the audit website. On pages 9 and 10 you will find the national mean averages, the scores for your hospital and the range of scores for each theme. To receive a full set of scores, hospitals were required to provide one complete organisational checklist, more than 19 casenotes, 20 or more eligible staff questionnaires and 10 or more carer questionnaires. Hospitals with fewer than the required number, have not received a score for that theme. Scores are derived from separate data sources and therefore should be viewed independently. For example, a hospital’s score for Assessment should only be compared to other Assessment scores, rather than the other scores for the same hospital. A hospital’s highest score may not reflect its area of greatest achievement, if it is a theme in which all hospitals have scored highly.




Case adjustment The impact of gender, age and ethnicity on scores were examined. The differences between the unadjusted and adjusted hospital scores were very small and there were no meaningful adjustments to be made. Therefore, all scores have been left in an unadjusted format.

Data breakdown by audit theme Audit standards are measured across the audit tools. Therefore, data submitted are presented thematically, with data from different tools presented together. The themes are:

1. Assessment

Data from the casenote audit. This looks at whether people with dementia admitted to

hospital have received a comprehensive assessment, and how well each element of

assessment is carried out.

2. Information and communication

Data from the organisational checklist, casenote audit, staff and carer questionnaires. This

looks at communication systems in use in the hospital, evidence of their use in casenotes and

presents feedback from carers and staff about the quality of communication.

3. Staffing and training

Data from the organisational checklist, staff questionnaire and carer questionnaire. This looks

at staffing provision, the extent of training delivery in hospitals and presents feedback from

staff on training quality.

4. Nutrition

Data from the organisational checklist and staff questionnaire. This looks at whether hospitals

have services that provide for the needs of people with dementia and presents feedback from

staff on service quality.

5. Discharge and hospital transfer

Data from the organisational checklist and casenote audit. This looks at the extent of planning

for discharge from hospital for people with dementia and whether they and their carers are

adequately informed.

6. Governance

Data from the organisational checklist, staff questionnaire and carer questionnaire. This looks

at the involvement of hospital leads and the Executive Board in leading, planning and

monitoring care, review of the environment and carer engagement.


Data tables in audit theme chapters Table 1: Explanation of how data tables are presented in audit theme chapters

When comparing Round 2 data with Round 3 data, please be aware that differences in sample sizes and slight wording changes to some questions, can affect results in both rounds. Comparison of the data should be made with caution. Quality Assurance visits Quality assurance visits were carried out to five randomly selected sites, and items checked across ten casenotes submitted, also randomly selected. It appears that there may be some variation in the ways in which sites are carrying out and recording some assessments and discharge planning. This may also affect your results. No adjustments were made to data following the quality assurance visits.

Data breakdown by audit tool Data has also been presented by audit tool. This can be found in the separate Appendices document. Inter-rater reliability Inter-rater reliability analysis was carried out for the casenote audit and full results are on the audit website. Any items with an inter-rater agreement of less than 0.5 have been highlighted in the casenote audit, Appendix C (Appendices in a separate document).

Std no. [Type]

Question number, tool and text

National audit Round 3:

% Num/Den

Your hospital Round 3:

% Num/Den


% Num/Den

Standard reference and type. Standards document

can be found on the audit website.

Audit tool that

item appears in and

question number.

Question wording

as in tool.

The national audit refers to all hospitals

from England and Wales that

participated in Round 3 of the audit.

Data for your hospital from

Round 3.

If the same question or a similar question was asked in Round 2, we have provided your Round 2 data, for

comparison. Therefore, the carer and staff

questionnaires are not represented in this

column.

We have provided the percentage ‘yes’ response (unless otherwise indicated) and the numerator/ denominator. The denominator will change throughout the report, depending on whether questions

were routed (not asked in some instances), ‘N/A’ responses chosen (these have been excluded from the analyses), or if staff and carers

did not respond to a question.






Mean average scores across England and Wales The scores presented below are the national mean averages from the 7 scoring themes, based on data submitted by 199 hospitals in England and Wales. A table with scores for each of the participating hospitals can be found in the National Report on the audit website.



The Countess of Chester Hospital scores Below are the scores derived from the data submitted by your hospital and your hospital ranking for each score. Some hospitals have not received a full set of scores if they submitted insufficient amounts of data. The scores are derived from separate data sources and should be viewed independently. For more information, please see page 6.

Table 2: Range of scores in the national sample, broken down by quartile

Score Highest scores - - - - - - - - - - - - - - - - - - - - - - - Lowest Scores

Governance 100% - 84.4% 81.3% - 65.6% 62.5% - 50% 48.4% - 12.5%

Nutrition 100% 95% - 87.5% 82.5% - 73.8% 68.8% - 36.3%

Discharge 98.5% - 85.2% 84.6% - 75.3% 75.2% - 63.6% 63.2% - 22%

Assessment 99.1% - 88.9% 88.6% - 85.4% 85.2% - 79.9% 79.7% - 48.7%

Staff rating of information & communication

82.7% - 68.5% 68.4% - 64.8% 64.7% - 61.6% 61.5% - 48.1%

Carer rating of information & communication

89.3% - 71.7% 71.5% - 63.4% 63.1% - 57.3% 57.2% - 22.2%

Carer rating of patient care 93.3% - 77.9% 77.8% - 72.4% 72.3% - 66.1% 64.7% - 21.7%

Table 3: Your hospital’s scores and rankings

Scoring Your hospital score Your hospital rank (out of)

Governance 56.3 121 (199)

Nutrition 68.8 152 (199)

Discharge 91 19 (195)

Assessment 90.5 35 (195)

Staff rating of information & communication

61.2 139 (182)

Carer rating of information & communication

- - (148)

Carer rating of patient care - - (148)


Key findings in local and national reporting The National Report for this round of audit contained five key messages derived from the national data set. These are shown below.

For local reporting, we have included graphical representations of data related to the key findings to allow for comparison between your hospital and the national results. These can be found starting on page 12.

Key findings from the National Report

Delirium recording requires improvement In more than half of casenotes of people with dementia, there was no recording of an initial screen or check for symptoms of delirium. Inconsistency in what is recorded and communicated may affect clinical care and thereby increase a person with dementia’s risk to developing delirium.

Personal information to support better care must be accessible A ward spot check carried out during the audit looked for the document with key personal information about care needs and communication that should be completed for people with dementia, and found that only half of these patients had one in place. Forty percent of staff said that they could not access this information most of the time, and under half of carers said definitely, staff were well informed.

Services must meet the nutritional needs of people with dementia Catering services should be able to provide for the needs of people with dementia, who may not be able to eat full meals at regular times and need finger food meal alternatives and snacks available at any time to ensure they are nourished. Less than 75% of staff said that they could obtain finger foods or snacks between meals for these patients. Twenty-four percent of staff thought people with dementia had nutritional needs met sometimes, or were not met.

Championing dementia means supporting staff To support staff to deliver better care, nearly all hospitals have created dementia champions at ward level. Just under 70% of carers gave a high rating to care overall. Staff said they needed more support, especially out of hours when less than a quarter of staff said they could access specialist support for dementia always or most of the time.

Involve the person with dementia in decision making Where a change in residence after discharge (e.g. from their own home to a care home) was proposed, just over one third of patients did not have their consent to begin this process recorded, or evidence that a best interests decision making process had taken place, in the case that they lacked capacity.


Key findings and The Countess of Chester Hospital

This section of the report presents some of the data and recommendations associated with the key

findings. Some additional questions from the carer questionnaire are also included. Each figure shows

the national mean average results next to the data for your hospital to allow for easy comparison. All

percentages have been rounded up to a whole number which means some results may calculate to

just under or over 100%. The national averages include data collected from 199 hospitals across

England and Wales.

The exact sample sizes for both the national sample and the sample for your hospital are presented in

the figure titles. Very low sample sizes (below ten) should be interpreted with caution. Sample sizes of

four or less are indicated in the title but are not shown on the graph (the bar for your hospital will be

blank and you will see a symbol () to indicate this) as they cannot be interpreted with reliability.

Delirium

Figure 1 shows the percentage of patients receiving an initial and full clinical assessment for delirium,

alongside the percentage of patients who had symptoms of delirium summarised (where applicable)

for discharge. All of this data is taken from the casenote audit.

Please note that initial delirium assessment is an item with lower than average inter-rater reliability

(full results can be found on the audit website). Therefore, your results may relate to inconsistency in

the recording of this assessment which may point to a need to agree local procedures to ensure that

this important information is consistently recorded and shared.

Figure 1: Percentage of patients who had: an initial screening for delirium, for the national sample

(n=10047) and your hospital (n=51); a clinical assessment for delirium following the screening, for the

national sample (n=2603) and your hospital (n=20); symptoms of delirium summarised for discharge,

for the national sample (n=2367) and your hospital (n=15).

45%

85%

48%

59%

70%

60%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Initial screening for delirium Clinical assessment for

delirium

Symptoms of delirium

summarised for discharge

% o

f case

no

tes

Type of delirium assessment

National average % Your hospital %


http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/nationalclinicalaudits/dementia/nationalauditofdementia.aspx

Key recommendations: Delirium

Medical and Nursing Directors should:

Ensure that hospitals have robust mechanisms in place for assessing delirium in people with

dementia including:

At admission, a full clinical delirium assessment, whenever indicators of delirium are identified.

Cognitive tests administered on admission and again before discharge.

Delirium screening and assessment fully documented in the patients notes (regardless of the

outcome).

Care offered in concordance with the delirium evidence-base recommendations when the

assessment indicates symptoms of delirium.

Results recorded on the electronic discharge summary.

Ensure staff receive training in delirium and its relationship to dementia, manifestations of pain,

and behavioural and psychological symptoms of dementia.

Personal information about the person with dementia

Information about the collection and use of personal information for people with dementia was

collected via the organisational checklist, casenote audit, staff questionnaire and carer questionnaire.

Although some items on the organisational checklist suggested that the use of personal information

collection tools was at close to 100%, items from the other audit tools suggest that in practice, this

figure is lower. Figures 2 to 5 show data about personal information collection in practice.

Hospitals were asked to complete a mini spot check of whether patients who should have a personal

information document in their notes had one. Figure 2 shows the results of this ‘mini audit’.

Figure 2: Results from the ‘mini audit’, showing the percentage of patients checked who had a

personal information document present. National sample (median number checked=10) and your

hospital sample (n=10).

49%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f p

ati

en

ts w

ith

a p

ers

on

al

info

rmati

on

do

cu

men

t


Figure 3 shows that some pieces of personal information are more often found in patient notes than

others. At a national level, the pieces of information recorded least often are factors which may cause

distress and actions which can help to calm the patient. An unknown response was provided for these

questions in Round 3 for hospitals to indicate where this information is usually recorded in a

document which accompanies the patient (e.g. “This is Me” or patient passport) and no copy was

available in the notes.

Figure 3: Percentage of casenotes where information about the person with dementia had been

collected. National sample and your hospital sample (see Appendix C for sample sizes).

The carer questionnaire asked carers how well informed they thought staff were about the needs of

the person with dementia. The results are shown in Figure 4.

47% 44%55%

33%28%

43%

33%34%

30%

38%39%

35%

20% 22%15%

29% 33%22%

77%

59%56%

29%24%

47%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Personal details

and

preferences

Food and drink

preferences

Support with

personal care

Factors may

cause distress

Actions which

can calm

patient

Details to aid

communication

% o

f case

no

tes

Information in the casenotes about the person with dementia

National average % (Yes responses) National average % (Unknown responses)

National average % (No responses) Your hospital % (Yes responses)


Figure 4: Carers’ perspective on how well informed staff were about the needs of the person with

dementia. National sample (n=4578) and your hospital sample (n=6).

The staff questionnaire also assessed availability of personal information for people with dementia by

asking staff whether this information was accessible to them. The results of this are shown in Figure 5.

Figure 5: Staff perspective on the availability of personal information to help them care for/support

people with dementia. National sample (n=14345) and your hospital sample (n=30).

47% 50%

43%

50%

10%0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f care

rs

Do you feel that hospital staff were well informed and understood the needs of the

person you look after?

Yes, definitely Yes, to some extent No

21%13%

39%

30%

33%

53%

7% 3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f st

aff

In your current role, do you think that personal information is available to you to

help you care for/ support people with dementia?

Yes, always Yes, most of the time Yes, sometimes No


Key recommendations: Personal information

National Commissioners (Welsh Government, NHS England) should propose a nationally

backed monitoring programme aimed at embedding the collection, sharing and use of person

centred information. This should include a clear expectation that once gathered, this information

will follow the patient between providers, and this will be monitored.

Ward Managers should audit implementation/use of personal information collected to improve

care for patients (e.g. This is Me or other locally developed document). The result of the audit

should be fed back to the dementia champions/dementia lead and ward staff.

Nutritional needs of people with dementia

The staff questionnaire collected data on aspects of patient nutrition and hydration. Figures 6, 7 and 8

show staff responses to three of these questions. Figure 6 shows that nationally, almost a quarter of

staff thought that the nutritional needs of people with dementia were not met at least most of the

time.

Figure 6: Staff perspective on meeting the nutritional needs of patients with dementia. National

sample (n=12263) and your hospital sample (n=27).

The staff questionnaire asked nurses and healthcare assistants working on wards at mealtimes about

accessing finger foods and snacks between meals for people with dementia. The results are presented

in Figures 7 and 8.

26%19%

50%59%

19% 19%

5% 4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f st

aff

Do you think that people with dementia you care for/ support, have their

nutritional needs met while on the ward(s) you work on?



Figure 7: Staff perspective on access to finger foods for people with dementia. National sample

(n=8822) and your hospital sample (n=22).

Figure 8: Staff perspective on access to snacks for people with dementia. National sample (n=9119)

and your hospital sample (n=22).

38%

68%

27%

23%23%

9%12%

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f st

aff

Can you access finger food for people with dementia as an alternative to main

meals?


45% 41%

29%46%

21%

14%6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f st

aff

Can you access snacks for people with dementia in between meals?



Key recommendations: Nutrition

Clinical Commissioning Groups and Health Board commissioning services should ensure that

tenders let by Trusts for new catering contracts always specify provision of finger foods for main

meals and access to a range of snacks 24 hours a day.

Medical and Nursing Directors should promote the attendance of key carers to support care,

but ensure that this is complementary to, and not instead of, care delivered by staff. The level of

input by carers, and how carers feel about the level of input they have been asked to deliver

should be monitored through carer feedback, complaints and PALS enquiries. Carer satisfaction

should be seen as a marker of good care. Ward managers should be supported to ensure carers

supporting patients should not be asked to leave at mealtimes/stopped from helping with meals

(this excludes emergency and urgent care and treatment).

Support for staff

The staff questionnaire asked staff about various aspects of support provided to them when caring for

or supporting people with dementia. Figures 9, 10 and 11 demonstrate how staff rated some of these

aspects of support. Figure 9 shows how prepared staff felt after completing one or more forms of

training provided by the hospital they currently work in. Responses where the respondent indicated

they were answering about training received elsewhere were not included in analyses.

Figure 9: Staff view of training provided by their current hospital. National sample (n=10670) and

your hospital sample (n=17).

The staff questionnaire also asked staff how well supported they felt by the specialist services for

dementia in their hospital. It is notable that the national view of the availability of support services out

of hours is rated much more negatively (Figure 11) than support during office hours (Figure 10).

Hospitals may wish to consider how they can improve the availability of this specialist support for staff

during the night and at weekends.

42%35%

51%

47%

7%18%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f st

aff

Following your training at this hospital, do you feel better prepared to provide

care/ support to people with dementia?

Yes, much better prepared Yes, somewhat better prepared No


Figure 10: Staff perspective on support available from specialist dementia services during office

hours. National sample (n=14024) and your hospital sample (n=29).

Figure 11: Staff perspective on support available from specialist dementia services out of hours.

National sample (n=11207) and your hospital sample (n=25).

Key recommendation: support for staff

The Chief Executive Officer should ensure that there is a dementia champion available to

support staff 24 hours per day, 7 days per week. This could be achieved through ensuring that

people in roles such as Site Nurse Practitioners and Bed Managers have expertise in dementia

care.

29%21%

33% 45%

27%28%

12%7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f st

aff

Do you feel supported by specialist services for dementia in your hospital during

office hours?


8%0%

16%

8%

28%

8%

49%

84%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f st

aff

Do you feel supported by specialist services for dementia in your hospital out of

office hours?



Involving the person with dementia in decision making

National data from England and Wales showed that in 34% of cases where a referral to a social worker

was made for a proposed change in residence post discharge, consent from the person with dementia

(or a best interests decision making process when the person did not have capacity to make this

decision) is not recorded in the notes. To compare this national data with data from your hospital,

please go to the discharge theme chapter (casenote audit, question 27).

Key recommendation: Decision making

The Safeguarding Lead should ensure that staff are trained in the Mental Capacity Act, including

consent, appropriate use of best interests decision making, the use of Lasting Power of Attorney

and Advance Decision Making. Training should cover supportive communication with family

members/carers on these topics.

The opinion of carers

One of the key aims for this round of audit was to collect feedback from carers which could be

compared across hospitals, and to ask them to rate the care that was received by the person they care

for, while in hospital. Hospitals report taking steps to involve carers, including development of

strategies for engaging carers and adopting the aims of John’s Campaign (allowing a family carer to

remain with a person with dementia and support them during admission). The carer questionnaire

aimed to see whether carers themselves reported the same. Below are some key points from the carer

questionnaire. Please also see your scores for overall carer rating of patient care, and carer rating of

information and communication on page 10.

At a national level, the most positively answered question on the carer questionnaire asked carers

whether the person they look after was treated with respect.

Figure 12: Carer perspective on whether the person with dementia was treated with respect. National

sample (n=4569) and your hospital sample (n=6).

76%83%

21%17%

3% 0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f care

rs

Was the person you look after treated with respect by hospital staff?

Yes, definitely Yes, to some extent No


Figure 13 shows data from the only question on the carer questionnaire which asked carers how well

supported they themselves felt by the hospital while the person they care for was admitted.

Figure 13: Carer view of support provided to them by the hospital. National sample (n=4379) and


The carer questionnaire also asked carers for their overall opinion of the care provided to the person

they care for while in hospital. This question makes up the score for carer rating of patient care.

Figure 14: Carer overall view of patient care provided by the hospital. National sample (n=4645) and


50% 50%

34%

50%

10%

0%6%

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f care

rs

Overall, how satisfied are you with the support you have received from this hospital

to help you in your role as a carer?

Very satisfied Somewhat satisfied Somewhat dissatisfied Very dissatisfied

35%

50%

34%

50%17%

0%

10%

0%5% 0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f care

rs

Overall, how would you rate the care received by the person you look after during

the hospital stay?

Excellent Very good Good Fair Poor


Assessment

Information and communication

Staffing and training

Nutrition

Discharge and hospital transfer

Governance

Audit themes


Assessment

Items presented in this theme are from the casenote audit and refer to assessments done upon or during admission. Assessments completed for discharge can be found in the discharge theme chapter.

Presentation of items and scoring

For information on how the data tables in the chapters are laid out, please see page 8.

The assessment theme has an associated score. The score for your hospital and the national mean average are shown in table 4. For further information on scoring, please see page 6.

Table 4: Assessment score for your hospital

Assessment score (%)

The Countess of Chester Hospital 90.5%

National average 83.7%


I. Multi-disciplinary assessment

Std no.

[Type] Question number and text


% Num/Den


% Num/Den


% Num/Den

1.9 [1]

14 CA

An assessment of mobility was performed by a healthcare professional: (y/n/could not be assessed for recorded reasons)

93.8% 8558/9126

100% 51/51

100% 40/40

15 CA

An assessment of nutritional status was performed by a healthcare professional: (y/n/could not be assessed for recorded reasons)

89.8% 8832/9837

90.2% 46/51

95% 38/40

15a CA

(If Q15=Yes) The assessment of nutritional status includes recording of BMI (Body Mass Index) or weight: Yes, there is a recording of the patient’s BMI or weight

85.9% 7580/8822

97.8% 45/46

100% 37/37

Other action taken 4%

352/8822 0%

0/46

New answer option for Round 3

1.10 [1]

16 CA

Has a formal pressure ulcer risk assessment been carried out and score recorded? (y/n)

95.5% 9590/10044

100% 51/51

100% 40/40

1.12 [1]

17 CA

As part of the multidisciplinary assessment has the patient been asked about any continence needs? (y/n/could not be assessed for recorded reasons)

88% 8572/9744

98% 49/50

97% 32/33

1.11 [1]

18 CA

As part of the multidisciplinary assessment has the patient been assessed for the presence of any pain? (y/n/could not be assessed for recorded reasons)

83.2% 8185/9840

100% 51/51

97.4% 38/39

1.13 [1]

19 CA

Has an assessment of functioning been carried out? Yes, a standardised assessment has taken place

45.3% 4212/9294

25.5% 13/51

86.5% 32/37

Yes, an occupational therapy and/or a physiotherapy assessment has taken place

42.8% 3977/9294

52.9% 27/51

New answer options for

Round 3 Yes, other

1.7% 161/9294

5.9% 3/51

Yes (all options) 89.8%

8350/9294 84.3% 43/51


II. Mental state assessment

Std no.



% Num/Den


% Num/Den


% Num/Den

1.3 [2]

20 CA

Has a standardised mental status test been carried out? (y/n/could not be assessed for recorded reasons)

54% 4684/8682

59.2% 29/49

31.6% 12/38

1.4 [2]

21 CA

Has an assessment been carried out for recent changes or fluctuation in behaviour that may indicate the presence of delirium? Yes, and there were indications that delirium may be present

25.9% 2603/10047

39.2% 20/51

52.5% 21/40

Yes, but there was no indication that delirium may be present

18.5% 1863/10047

19.6% 10/51

32.5% 13/40

Yes (both options) 44.5%

4466/10047 58.8% 30/51

85% 34/40

1.5 [2]

21a CA

(If Q21=Yes) Has the patient been clinically assessed for delirium by a healthcare professional? (y/n)

85.3% 2220/2603

70% 14/20

95.2% 20/21


Information and Communication

Items presented in this theme are from the organisational checklist, casenote audit, staff questionnaire and carer questionnaire. The questions relate to personal information collected about people with dementia, communication between staff members and communication between staff and carers.



The information and communication theme has two associated scores. One score for carer rating of information and communication and one for staff rating of information and communication. The scores for your hospital and the national mean averages are shown in table 5. For further information on scoring, please see page 6.

Table 5: Information and communication scores for your hospital

Carer rating (%) Staff rating (%)

The Countess of Chester Hospital -% 61.2%

National average 64.4% 64.8%


I. Information about the patient with dementia a. Data from the organisational checklist and casenote audit

Std no.



% Num/Den


% Num/Den


% Num/Den

1.14 [1]

16 OC

There is a formal system (pro-forma or template) in place in the hospital for gathering information pertinent to caring for a person with dementia: (y/n)

98.5% 196/199

Yes Yes

22 CA

Does the care assessment contain a section dedicated to collecting information from the carer, next of kin or a person who knows the patient well? (y/n)

57.2% 5727/10010

66.7% 34/51

95% 38/40

17a OC

(If Q16=Yes) Information collected by the pro-forma includes personal details, preferences and routines: (y/n)

100% 196/196

Yes Yes

22a CA

(If Q22=Yes) Has information been collected about the patient regarding personal details, preferences and routines?

Yes 47.4%

2669/5626 76.5% 26/34

86.8% 33/38

Unknown* 33.1%

1865/5626 5.9% 2/34


17b OC

(If Q16=Yes) Information collected by the pro-forma includes reminders or support with personal care: (y/n)

98.5% 193/196

Yes Yes

22c CA

(If Q22=Yes) Has information been collected about the patient regarding reminders or support with personal care?

Yes 55.3%

3116/5631 55.9% 19/34

73.7% 28/38

Unknown* 29.9%

1685/5631 17.6% 6/34


17c OC

(If Q16=Yes) Information collected by the pro-forma includes recurring factors that may cause or exacerbate distress: (y/n)

100% 196/196

Yes Yes

22d CA

(If Q22=Yes) Has information been collected about the patient regarding recurring factors that may cause or exacerbate distress?

Yes 32.6%

1818/5583 29.4% 10/34

42.1% 16/38

Unknown* 37.8%

2110/5583 20.6% 7/34


17d OC

(If Q16=Yes) Information collected by the pro-forma includes support or actions that can calm the person if they are agitated: (y/n)

99% 194/196

Yes Yes


Std no.



% Num/Den


% Num/Den


% Num/Den

22e CA

(If Q22=Yes) Has information been collected about the patient regarding support or actions that can calm the person if they are agitated?

Yes 28.2%

1564/5539 23.5% 8/34

34.2% 13/38

Unknown* 39.1%

2167/5539 20.6% 7/34


18 OC

(If Q16=Yes) Information collected by the pro-forma includes how the person with dementia communicates with others/ understands communication: (y/n)

99.5% 195/196

Yes New question for Round 3

1.15 [3]

17e OC

(If Q16=Yes) Information collected by the pro-forma includes life details which aid communication: (y/n)

99.5% 195/196

No Yes

22f CA

(If Q22=Yes) Has information been collected about the patient regarding life details which aid communication?

Yes 43.1%

2413/5598 47.1% 16/34

52.6% 20/38

Unknown* 35.3%

1977/5598 17.6% 6/34


1.14 [1]

22b CA

(If Q22=Yes) Has information been collected about the patient's food and drink preferences?

Yes 44.1%

2476/5616 58.8% 20/34 New question

for Round 3 Unknown*

34.1% 1916/5616

11.8% 4/34

19 OC

(If Q16=Yes) The form prompts staff to approach carers or relatives to collate necessary information: (y/n)

93.4% 183/196

Yes Yes

20 OC

Documenting use of personal information in practice: Hospitals selected three adult inpatient wards which had the highest admissions of people with dementia. Ten patients in these wards were checked to see if the personal information document was present. Included were patients with dementia who needed a personal information document such as “This is Me” Number of patients checked: - 10

New question for Round 3

Range 0-40 - Median 10 - Number of these patients where the information was present:

- 3


Percentage of patients where the information was present:

- 30%

Range 0-100% - Mean 49% - Median 50% -

*Unknown response options refer to situations in which the information is usually recorded in a document which

accompanies the patient (e.g. “This is Me” or patient passport) and no copy is available in the notes.


b. Data from the carer and staff questionnaires

Std no.



% Num/Den


% Num/Den


% Num/Den

1.14 [1]

7 CQ

Did hospital staff ask you about the needs of the person you look after to help plan their care?

Yes, definitely 45.4%

2053/4524 50% 3/6

New tool for Round 3

Yes, to some extent 34.5%

1563/4524 50% 3/6

No 20.1%

908/4524 0% 0/6

9.3 [1]

1 CQ

Do you feel that hospital staff were well informed and understood the needs of the person you look after?


2130/4578 50% 3/6



1980/4578 50% 3/6

No 10.2%

468/4578 0% 0/6

3 SQ

In your current role, do you think that personal information is available to you to help you care for/ support people with dementia? E.g. their likes/ dislikes, preferred name, past job.

Yes, always 21.4%

3072/14345 13.3% 4/30


Yes, most of the time 38.5%

5525/14345 30% 9/30

Yes, sometimes 33%

4734/14345 53.3% 16/30

No 7.1%

1014/14345 3.3% 1/30

3a SQ

Do you have the opportunity to use this information to help you care for/ support people with dementia?

Yes, always 26.6%

3549/13329 6.9% 2/29



5454/13329 41.4% 12/29

Yes, sometimes 30.6%

4074/13329 51.7% 15/29

No 1.9%

252/13329 0%

0/29

7.4 [2]

4 SQ

In your current role, do you feel encouraged to accommodate the individual needs and preferences of people with dementia? E.g. taking time to speak and interact at the pace of the person with dementia, permitting them to walk around the ward.

Yes, always 28.9%

4145/14333 20% 6/30



4759/14333 30% 9/30


3913/14333 40% 12/30

No 10.6%

1516/14333 10% 3/30


Std no.



% Num/Den


% Num/Den


% Num/Den

2 CQ

Do you feel confident that hospital staff delivered high quality care that was appropriate to the needs of the person you look after?


2489/4592 83.3%

5/6 New tool for

Round 3 Yes, to some extent

36.4% 1672/4592

16.7% 1/6

No 9.4%

431/4592 0% 0/6

4 CQ

Was the person you look after treated with respect by hospital staff?

Yes, definitely 76%

3471/4569 83.3%

5/6 New tool for


20.8% 952/4569

16.7% 1/6

No 3.2%

146/4569 0% 0/6

II. Communication between staff

Std no.



% Num/Den


% Num/Den


% Num/Den

9.3 [1]

21 OC

There is a system in place across the hospital that ensures that all staff in the ward or care area are aware of the person's dementia or condition and how it affects them: (y/n)

90.5% 180/199

Yes Yes

21a OC

(If Q21=Yes) Please say what this is:

A visual indicator, symbol or marker 91.1%

164/180 √

A visual indicator, symbol or

marker

Alert sheet or electronic flag (updated option for Round 3)

23.9% 43/180

-

A box to highlight or alert dementia condition in the notes or care plan

33.9% 61/180

√

Other 18.9% 34/180

-

22 OC

There is a system in place across the hospital that ensures that staff from other areas are aware of the person's dementia or condition whenever the person accesses other treatment areas: (y/n)

70.4% 140/199

Yes Yes


Std no.



% Num/Den


% Num/Den


% Num/Den

9.3 [1]

22a OC

(If Q22=Yes) Please say what this is:

A visual indicator, symbol or marker 87.1%

122/140 -

A visual indicator, symbol or

marker

Alert sheet or electronic flag (Updated option for Round 3)

18.6% 26/140

-

A box to highlight or alert dementia condition in the notes or care plan

20.7% 29/140

√

Other 17.9% 25/140

-

7.12 [1]

6 SQ

As a team, how often do you talk about the way you care for/ support people with complex needs (including dementia)?

Frequently 49.8%

6203/12457 65.4% 17/26


Occasionally 37.2%

4636/12457 23.1% 6/26

Almost Never 9.7%

1210/12457 3.8% 1/26

Never 3.3%

408/12457 7.7% 2/26

III. Involvement of carers and people with dementia

Std no.



% Num/Den


% Num/Den


% Num/Den

9.7 [2]

5 CQ

Were you (or the patient, where appropriate) kept clearly informed about their care and progress during the hospital stay? For example, about plans for treatment and discharge.


1908/4566 50% 3/6



1843/4566 50% 3/6

No 17.8%

815/4566 0% 0/6

9.11 [2]

6 CQ

Were you (or the patient, where appropriate) involved as much as you wanted to be in decisions about their care?


2138/4497 50% 3/6



1637/4497 50% 3/6

No 16.1%

722/4497 0% 0/6

9.13 [2]

23 OC

The dementia lead or dementia working group collates feedback from carers on the written and verbal information provided to them: (y/n)

81.9% 163/199



Staffing and Training

Items presented in this theme are from the organisational checklist, staff questionnaire and carer questionnaire. Questions relate to hospital staffing levels and the training available to staff on dementia care.



The staffing and training theme has no associated score. This is because there was insufficient data nationally for this theme. For further information on scoring, please see page 6.


I. Staffing levels

Std no.



% Num/Den


% Num/Den


% Num/Den

N7a [3]

10 OC

Ward staffing levels (nurses, midwives and care staff) are made available for the public to view on a monthly basis: (y/n)

88.4% 176/199


11 OC

An evidence-based tool is used for establishing ward staffing levels: (y/n)

99% 197/199


4.9 [2]

9 SQ

Do you think the ward(s) you work on is able to respond to the individual needs of people with dementia as they arise? E.g. pain relief, personal care, toileting, mobility assistance.

Yes, always 30.4%

2785/9148 13.6% 3/22



4352/9148 45.5% 10/22


1708/9148 31.8% 7/22

No 3.3%

303/9148 9.1% 2/22

10 SQ

Is additional staffing support provided if dependency needs on the ward(s) you work on increase?

Yes, always 10.7%

977/9143 4.5% 1/22



2516/9143 13.6% 3/22


3887/9143 54.5% 12/22

No 19.3%

1763/9143 27.3% 6/22

1.14 [1]

3 CQ

Was the person you look after given enough help with personal care from hospital staff? For example, eating, drinking, washing and using the toilet.


2456/4433 83.3%

5/6 New tool for


34.2% 1515/4433

16.7% 1/6

No 10.4%

462/4433 0% 0/6

II. Guidance for staff

Std no.



% Num/Den


% Num/Den


% Num/Den

7.1 [2]

31 OC

There is a named dignity lead to provide guidance, advice and consultation to staff: (y/n)

70.4% 140/199

Yes Yes


III. Training and knowledge framework

Std no.



% Num/Den


% Num/Den


% Num/Den

7.2 [2]

24 OC

There is a training and knowledge framework or strategy that identifies necessary skill development in working with and caring for people with dementia: (y/n)

95.5% 190/199

Yes Yes

7.11 [3]

26 OC

Involvement of people with dementia and carers and use of their experiences is included in the training for ward staff: (y/n)

82.4% 164/199

No Yes

IV. Dementia care training

Std no.



% Num/Den


% Num/Den


% Num/Den

7.5 [3]

27 OC

What format is used to deliver basic dementia awareness training?

eLearning module 72.9%

145/199 -


Workshop or study day 91%

181/199 √

Higher education module 22.6% 45/199

-

Other 29.1% 58/199

-

7.4 [2]

2 SQ

What form did your dementia training at this hospital take? Please tick all that apply:

eLearning module 42.8%

5653/13205 6.9% 2/29


Workshop or study day 53.2%

7030/13205 51.7% 15/29

Higher education module 5.4%

713/13205 6.9% 2/29

Workbook 7.7%

1018/13205 6.9% 2/29

Other 7.3%

961/13205 10.3% 3/29

I have not received any dementia training at this hospital

17.3% 2278/13205

34.5% 10/29

2a SQ

Following your training at this hospital, do you feel better prepared to provide care/ support to people with dementia?

Yes, much better prepared 42.2%

4502/10670 35.3% 6/17


Yes, somewhat better prepared 50.5%

5390/10670 47.1% 8/17

No 7.3%

778/10670 17.6% 3/17


Std no.



% Num/Den


% Num/Den


% Num/Den

25 OC

The question below is about training that is provided to acute healthcare staff who are involved in the care of people with dementia (or suspected dementia): Dementia awareness training is:

Doctors

Mandatory 46.2% 92/199

√ -

Provided on induction 63.3%

126/199 - -

Provided in the last 12 months 58.8%

117/199 - -

Not provided in the last 12 months 8.5%

17/199 - √

Nurses

Mandatory 51.8%

103/199 √ -


148/199 - √


136/199 - √

Not provided in the last 12 months 1%

2/199 - -

Healthcare assistants

Mandatory 51.8%

103/199 √ -


142/199 - √


136/199 - √

Not provided in the last 12 months 1%

2/199 - -

Other allied healthcare professionals, e.g. physiotherapists, dieticians


√ -


129/199 - -


135/199 - -

Not provided in the last 12 months 3.5% 7/199

- √

Support staff in the hospital, e.g. housekeepers, porters, receptionists


√ -


115/199 - -


127/199 - -

Not provided in the last 12 months 11.1% 22/199

- √


Nutrition

Items presented in this theme are from the organisational checklist and staff questionnaire. Questions relate to the provision of food and drink for people with dementia and hospital schemes such as protected mealtimes.



The nutrition theme has an associated score. The score for your hospital and the national mean average are shown in table 6. For further information on scoring, please see page 6.

Table 6: Nutrition score for your hospital

Nutrition score (%)




I. Protected mealtimes

Std no.



% Num/Den


% Num/Den


% Num/Den

3.7 [1]

12 OC

Protected mealtimes are established in all wards that admit adults with known or suspected dementia: (y/n)

98% 195/199

Yes Yes

12a OC

(If Q12=Yes) Wards’ adherence to protected mealtimes is reviewed and monitored: (y/n)

88.7% 173/195

Yes Yes

12 SQ

In the last week (except in emergency situations), were patient mealtimes kept free of any clinical activity on the ward(s) you work on?

Yes, always 28.3%

2488/8788 18.2% 4/22



3456/8788 50% 11/22


1476/8788 13.6% 3/22

No 15.6%

1368/8788 18.2% 4/22

3.8 [1]

13 OC

The hospital has in place a scheme/ programme which allows identified carers of people with dementia to visit at any time including at mealtimes (e.g. Carer’s Passport): (y/n)

88.9% 177/199

No New question for Round 3

7 SQ

Can carers of people with dementia visit at any time on the ward(s) you work on? i.e. visits are not limited to normal visiting hours and may include mealtimes.

Yes, always 51.2%

6131/11978 40.7% 11/27



3271/11978 29.6% 8/27


1927/11978 14.8% 4/27

No 5.4%

649/11978 14.8% 4/27


II. Catering arrangements

Std no.



% Num/Den


% Num/Den


% Num/Den

N3b [2]

35 OC

The hospital can provide finger foods for people with dementia (please select one option only): Patients can choose a complete meal option (including vegetarian) that can be eaten without cutlery (finger food) on every day

65.3% 130/199

√


Patients can choose a complete meal option (including vegetarian) that can be eaten without cutlery on four to six days per week or more

1% 2/199

-

Patients can choose a complete meal option (including vegetarian) that can be eaten without cutlery on two or three days per week or more

0% 0/199

-

Patients can choose a complete meal option (including vegetarian) that can be eaten without cutlery on only one day per week

0% 0/199

-

Finger food consists of sandwiches/wraps only 33.7% 67/199

-

Patients who may be unable to use cutlery will never be admitted to the hospital

0% 0/199

-

13 SQ

Can you access finger food (i.e. food which can be eaten without a knife/ fork/ spoon) for people with dementia as an alternative to main meals?

Yes, always 38%

3356/8822 68.2% 15/22



2398/8822 22.7% 5/22


1983/8822 9.1% 2/22

No 12.3%

1085/8822 0%

0/22

3.11 [2]

36 OC

The hospital can provide 24 hour food services for people with dementia (please select one option only): In addition to the main meals, other food, for example toast, sandwiches, cereals, soup, and lighter hot dish(es) are available 24 hours a day

50.8% 101/199

-


In addition to the main meals, other food, for example toast, sandwiches, cereals, soup are available, but less than 24 hours a day

10.6% 21/199

√

Simple food supplies for example bread, cereal, yoghurt and biscuits are available 24 hours a day

32.2% 64/199

-

Only snacks (biscuits, cake) are available 24 hours a day

3% 6/199

-

Food is not available 24 hours a day 3.5% 7/199

-


Std no.



% Num/Den


% Num/Den


% Num/Den

14 SQ

Can you access snacks for people with dementia in between meals?

Yes, always 44.5%

4060/9119 40.9% 9/22



2615/9119 45.5% 10/22


1886/9119 13.6% 3/22

No 6.1%

558/9119 0%

0/22

III. Communication

Std no.



% Num/Den


% Num/Den


% Num/Den

N3a [2]

15 SQ

Are the nutrition and hydration needs of people with dementia communicated at handovers/ safety briefings?

Yes, always 46.2%

4199/9090 45.5% 10/22



3039/9090 40.9% 9/22


1408/9090 13.6% 3/22

No 4.9%

444/9090 0%

0/22

IV. Overall

Std no.



% Num/Den


% Num/Den


% Num/Den

7.18 [1]

8 SQ

Do you think that the people with dementia you care for/ support, have their nutritional needs met while on the ward(s) you work on?

Yes, always 25.9%

3181/12263 18.5% 5/27



6149/12263 59.3% 16/27


2357/12263 18.5% 5/27

No 4.7%

576/12263 3.7% 1/27


Discharge

Items presented in this theme are from the organisational checklist and the casenote audit. The questions ask about discharge planning, assessment for discharge and discharge notice.



The discharge theme has an associated score. The score for your hospital and the national mean average are shown in table 7. For further information on scoring, please see page 6.

Table 7: Discharge score for your hospital

Discharge planning score (%)

The Countess of Chester Hospital 91%



I. Assessment before discharge

Std no.



% Num/Den


% Num/Den


% Num/Den

5.3 [2]

23 CA

At the point of discharge the patient's level of cognitive impairment, using a standardised assessment, was summarised and recorded: (y/n)

22.4% 1639/7329

37.5% 12/32

23.3% 7/30

23a CA

(If 23=No) Please comment:

Patient too unwell/ not responsive 3.3%

189/5690 0%

0/20


Patient has advanced dementia (i.e. patient’s advanced dementia makes the assessment not appropriate)

1.9% 110/5690

0% 0/20

Not routine/ not standard practice 5.8%

331/5690 0%

0/20

Not documented/ unknown reason 78.1%

4444/5690 95% 19/20

Dementia diagnosis (i.e. dementia diagnosis mentioned as a reason for not completing assessment)

10.8% 616/5690

5% 1/20

24 CA

At the point of discharge the cause of cognitive impairment was summarised and recorded: (y/n)

69.1% 5067/7329

87.5% 28/32

60% 18/30

25 CA

Have there been any symptoms of delirium? (y/n)

32.3% 2367/7329

46.9% 15/32

66.7% 20/30

25a CA

(If Q25=Yes) Have the symptoms of delirium been summarised for discharge? (y/n)

47.9% 1133/2367

60% 9/15

55% 11/20

26 CA

Have there been any persistent behavioural and psychiatric symptoms of dementia (wandering, aggression, shouting) during this admission? (y/n)

19.4% 1425/7329

43.8% 14/32

73.3% 22/30

26a CA

(If Q26=Yes) Have the symptoms of behavioural and psychiatric symptoms of dementia been summarised for discharge? (y/n)

44.5% 635/1426

50% 7/14

63.6% 14/22


Std no.



% Num/Den


% Num/Den


% Num/Den

27 CA

Is there a recorded referral to a social worker for assessment of housing and care needs due to a proposed change in residence?

65.5% 1649/2519

100% 3/3


27a (i) CA

(If Q27=Yes): There are documented concerns about the patient’s capacity to consent to the referral:

70.4% 1161/1649

33.3% 1/3


27a (ii) CA

The patient had capacity on assessment and their consent is documented

11.9% 138/1161

0% 0/1

The patient lacked requisite capacity and evidence of a best interests decision has been recorded

69.9% 811/1161

100% 1/1

There is no record of either consent or best interest decision making*

18.3% 212/1161

0% 0/1

27a (i) CA

There are no documented concerns about the patient’s capacity to consent to the referral:

29.6% 488/1649

66.7% 2/3

27a (iii) CA

The patients consent was requested and this is recorded

29.1% 142/488

50% 1/2

There is no record of the patients consent*

70.9% 346/488

50% 1/2

27a (ii & iii) CA

Consent or best interests (responses options combined)

66.2% 1091/1649

66.7% 2/3

No consent or best interests (response options combined)

33.8% 558/1649

33.3% 1/3

5.5 [2]

36 CA

An assessment of the carer's current needs has taken place in advance of discharge: (y/n/na)

67.3% 2605/3868

100% 11/11

100% 26/26

*Please note that these figures include 1.9% of casenotes where it was specified that the capacity assessment information is kept with social worker notes, which are unavailable to the auditor.

I. Discharge planning and coordination

Std no.



% Num/Den


% Num/Den


% Num/Den

6.4 [2]

32 OC

There is a named person/ identified team who takes overall responsibility for complex needs discharge and this includes people with dementia: (y/n)

95.5% 190/199

Yes Yes

6.5 [2]

33a OC

(If Q32=Yes) This person/ team has training in ongoing needs of people with dementia: (y/n)

92.6% 176/190

Yes Yes

6.6 [3]

33b OC

(If Q32=Yes) This person/ team has experience of working with people with dementia and their carers: (y/n)

98.4% 187/190

Yes Yes


Std no.



% Num/Den


% Num/Den


% Num/Den

6.4 [2]

28 CA

Did a named person/ identified team co-ordinate the discharge plan? (y/n/na)

82% 5807/7083

96.8% 30/31

96.7% 29/30

5.4 [1]

29a CA

Is there evidence in the notes that the discharge coordinator/ person or team planning discharge has discussed place of discharge and support needs with the person with dementia? (y/n/na)

53.9% 3327/6169

80% 16/20

92.3% 24/26

29b CA

Is there evidence in the notes that the discharge coordinator/ person or team planning discharge has discussed place of discharge and support needs with the person's carer/ relative? (y/n/na)

80.7% 5597/6935

90.3% 28/31

100% 30/30

29c CA

Is there evidence in the notes that the discharge coordinator/ person or team planning discharge has discussed place of discharge and support needs with the consultant responsible for the patient's care? (y/n)

75.1% 5501/7329

96.9% 31/32

73.3% 22/30

29d CA

Is there evidence in the notes that the discharge coordinator/ person or team planning discharge has discussed place of discharge and support needs with other members of the multidisciplinary team? (y/n)

81.5% 5971/7329

96.9% 31/32

100% 30/30

5.6 [1]

30 CA

Has a single plan/ summary for discharge with clear updated information been produced? (y/n)

85.1% 6234/7329

75% 24/32

86.7% 26/30

5.7 [2]

31 CA

Are any support needs that have been identified documented in the discharge plan/ summary? (y/n/na)

60.2% 4211/6995

93.1% 27/29

85.2% 23/27

5.8 [1]

32 CA

Has the patient and/ or carer received a copy of the plan/ summary? (y/n/na)

80.6% 5621/6975

78.1% 25/32

50% 15/30


Std no.



% Num/Den


% Num/Den


% Num/Den

5.1 [2]

34 CA

Was discharge planning initiated within 24 hours of admission? (y/n/na)

47.4% 2483/5242

62.1% 18/29

78.3% 18/23

34a CA

(If Q34=N/A) Please select the recorded reason why discharge planning could not be initiated within 24 hours:

Patient acutely unwell 62.5%

1306/2088 100%

3/3 14.3%

1/7

Patient awaiting assessment 9.1%

190/2088 0% 0/3

14.3% 1/7

Patient awaiting history/ results 6.1%

127/2088 0% 0/3

14.3% 1/7

Patient awaiting surgery 9.6%

200/2088 0% 0/3

14.3% 1/7

Patient presenting confusion 5.7%

120/2088 0% 0/3

14.3% 1/7

Patient on end of life plan 0%

1/2088 0% 0/3

-

Patient being transferred to another hospital 0.1%

2/2088 0% 0/3

0% 0/7

Patient unresponsive 0.3%

6/2088 0% 0/3

0% 0/7

Patient being discharged to nursing/ residential care

6.5% 136/2088

0% 0/3

0% 0/7

Not recorded - - 14.3%

1/7

Other 0%

0/2088 0% 0/3

14.3% 1/7

II. Notice of discharge

Std no.



% Num/Den


% Num/Den


% Num/Den

N5a [3]

14 OC

Instances where less than 24 hours notice of discharge has been given to carers or family are compiled and reported to the Executive Board:

Yes, within the past 6 months 4%

8/199 No


Yes, within the last year 1.5% 3/199


Std no.



% Num/Den


% Num/Den


% Num/Den

5.10 [2]

35 CA

Carers or family have received notice of discharge and this is documented:

Less than 24 hours 19.5%

1432/7329 9.4% 3/32

16.7% 5/30

24 hours 12.2%

897/7329 6.3% 2/32

3.3% 1/30

25 - 48 hours 14.7%

1075/7329 6.3% 2/32

36.7% 11/30

More than 48 hours 27.1%

1985/7329 65.6% 21/32

40% 12/30

No notice at all 0.5%

35/7329 0%

0/32 0%

0/30

Not documented 24.2%

1770/7329 12.5% 4/32

3.3% 1/30

No carer, family, friend/ could not contact 1.8%

132/7329 0%

0/32 0%

0/30

Patient specified information to be withheld 0%

3/7329 0%

0/32


N5b [2]

33 CA

Was a copy of the discharge plan/ summary sent to the GP/ primary care team on the day of discharge? (y/n/na)

93.6% 6701/7156

100% 32/32



Governance

Items presented in this theme are from the organisational checklist, staff questionnaire and carer questionnaire. The questions relate to such topics as the environment in the hospital, involvement of the executive board, services available to carers and patients and engagement with carers.



The governance theme has an associated score. The score for your hospital and the national mean average are shown in table 8. For further information on scoring, please see page 6.

Table 8: Governance score for your hospital

Governance score (%)




I. Environment a. Physical environment on the ward

Std no.



% Num/Den


% Num/Den


% Num/Den

N8a [3]

39 OC

The physical environment within the hospital has been reviewed using an appropriate tool (e.g. King’s Fund Enhancing the Healing Environment) to establish whether it is “dementia-friendly”:

Throughout the hospital 42.7% 85/199

√


All adult wards/ areas 13.6% 27/199

-

All care of the elderly wards/ areas 18.1% 36/199

-

Designated dementia wards only 3%

6/199 -

Other 13.1% 26/199

-

No 9.5%

19/199 -

40 OC

(If Q39=Yes) Environmental changes based on the review are:

Completed 15%

27/180 -


Underway 56.7%

102/180 -

Planned but not yet underway 10%

18/180 -

Planned but funding has not been identified 15.6% 28/180

√

Plans are not in place 2.8% 5/180

-

41 OC

(If Q39=Yes) Service users/ carers/ lay volunteers have been part of the team reviewing the environment:

Throughout the hospital 36.7% 66/180

-


All adult wards/ areas 9.4%

17/180 -

All care of the elderly wards/ areas 13.3% 24/180

-

Designated dementia wards only 5%

9/180 -

Other 13.3% 24/180

-

They have not been part of the team 22.2% 40/180

√


Std no.



% Num/Den


% Num/Den


% Num/Den

42 OC

(If Q39=Yes) There are plans to further review the changes implemented: Yes, we are already undertaking/ have already done this

49.4% 89/180

-


Yes, once the work is completed 40%

72/180 √

No plans are in place 10.6% 19/180

-

b. Social environment on the ward

Std no.



% Num/Den


% Num/Den


% Num/Den

6.11 [3]

38 OC

Opportunities for social interaction for patients with dementia are available (e.g. to eat/ socialise away from their bed area with other patients):

On all adult wards 15.1% 30/199

-


On care of the elderly wards 38.7% 77/199

-

Other 30.2% 60/199

-

No 16.1% 32/199

√

II. Dementia champions and specialist services

Std no.



% Num/Den


% Num/Den


% Num/Den

4.11 [2]

5 OC

There are champions for dementia at:

5a OC

Directorate level (y/n) 81.9%

163/199 Yes Yes

5b OC

Ward level (y/n) 93.5%

186/199 Yes Yes


Std no.



% Num/Den


% Num/Den


% Num/Den

1 SQ

Do you feel supported by specialist services for dementia in your hospital? E.g. dementia specialist team, mental health liaison, dementia champions.

1a SQ

During office hours i.e. Monday-Fri, 9am-5pm

Yes, always 28.7%

4026/14024 20.7% 6/29



4614/14024 44.8% 13/29


3760/14024 27.6% 8/29

No 11.6%

1624/14024 6.9% 2/29

1b SQ

Out of office hours

Yes, always 7.8%

874/11207 0%

0/25



1763/11207 8%

2/25


3129/11207 8%

2/25

No 48.6%

5441/11207 84% 21/25

III. Continuity of care

Std no.



% Num/Den


% Num/Den


% Num/Den

N3c [3]

15 OC

Instances of night time bed moves (i.e. between the evening meal and breakfast the next morning) are noted and reported at Executive Board level: (y/n)

38.2% 76/199


11 SQ

Are night time bed moves for people with dementia avoided where possible on the ward(s) you work on? By night time bed moves, we mean bed moves between the evening meal and breakfast the next morning.

Yes, always 16.3%

1474/9047 0%

0/22



2942/9047 13.6% 3/22


2506/9047 22.7% 5/22

No 23.5%

2125/9047 63.6% 14/22

6.2 [2]

30 OC

The hospital has access to intermediate care services, which will admit people with dementia: (y/n)

93% 185/199

Yes Yes


Std no.



% Num/Den


% Num/Den


% Num/Den

6.3 [3]

30a OC

(If Q30=Yes) Access to intermediate care services allows people with dementia to be admitted to intermediate care directly and avoid unnecessary hospital admission: (y/n)

84.3% 156/185

Yes No

IV. Engagement with carers

Std no.



% Num/Den


% Num/Den


% Num/Den

N4b [3]

7 OC

Has a strategy or plan for carer engagement been produced (e.g. using Triangle of Care self-assessment tool)? (y/n)

76.9% 153/199


8 OC

(If Q7=Yes) Is implementation of the strategy or plan scheduled for review?

Yes, more than once a year 41.2% 63/153

Yes, more than once a

year


Yes, once a year 34.6% 53/153

Yes, less than once a year 20.3% 31/153

6.7 [2]

34 OC

There is a social worker or other designated person or team responsible for working with people with dementia and their carers, and providing advice and support, or directing to appropriate organisations or agencies: (y/n)

75.9% 151/199

Yes Yes

6.10 [2]

37 OC

There is access to advocacy services with experience and training in working with people with dementia: (y/n)

95% 189/199

Yes Yes

8

CQ

Overall, how would you rate the care received by the person you look after during the hospital stay?

Excellent 34.5%

1602/4645 50% 3/6


Very good 33.9%

1575/4645 50% 3/6

Good 17%

790/4645 0% 0/6

Fair 9.6%

446/4645 0% 0/6

Poor 5%

232/4645 0% 0/6


Std no.



% Num/Den


% Num/Den


% Num/Den

10 CQ

Overall, how satisfied are you with the support you have received from this hospital to help you in your role as a carer?

Very satisfied 50.3%

2204/4379 50% 3/6


Somewhat satisfied 34%

1487/4379 50% 3/6

Somewhat dissatisfied 9.9%

434/4379 0% 0/6

Very dissatisfied 5.8%

254/4379 0% 0/6

V. Involvement of the executive board

Std no.



% Num/Den


% Num/Den


% Num/Den

4.4 [2]

3 OC

The Executive Board regularly reviews the number of in-hospital falls and the breakdown of the immediate causes, in which patients with dementia can be identified (y/n)

60.3% 120/199

No Yes

4.5 [2]

4 OC

The Executive Board regularly receives feedback from the following:

4a OC

Clinical Leads for older people and people with dementia including Modern Matrons/ Nurse Consultant (y/n)

84.9% 169/199

Yes Yes

4b OC

Complaints – analysed by age (y/n) 52.3%

104/199 Yes Yes

4c OC

Patient Advice and Liaison Services (PALS) – in relation to the services for older people and people with dementia (y/n/na)

58.6% 106/181

Yes Yes

4d OC

Patient/ public forums or local Healthwatch – in relation to services for older people and people with dementia (y/n)

67.3% 134/199

Yes Yes

4.7 [2]

2 OC

The Executive Board regularly reviews information collected on:

2a OC

Re-admissions, in which patients with dementia can be identified in the total number of patients re-admitted (y/n)

31.7% 63/199

No Yes

2b OC

Delayed discharge/ transfers, in which patients with dementia can be identified in the total number of patients with delayed discharge/ transfers (y/n)

31.7% 63/199

No Yes


VI. Dementia working groups

Std no.



% Num/Den


% Num/Den


% Num/Den

N4c [3]

9 OC

A Dementia Working Group is in place and reviews the quality of services provided in the hospital: (y/n)

93.5% 186/199


9a OC

(If Q9=Yes) The group meets:

Annually 0.5% 1/186

Bi-monthly New question for Round 3

Bi-annually 0.5% 1/186

Quarterly 30.1% 56/186

Six-weekly 4.3% 8/186

Monthly 33.3% 62/186

Bi-monthly 29%

54/186

Weekly 0.5% 1/186

Unknown 1.6% 3/186

9b OC

(If Q9=Yes) The group includes:

Healthcare professionals 100%

186/186 √


Organisations e.g. Alzheimer’s Society 64%

119/186 √

Carer/ service user representation 66.1%

123/186 -

VII. Care pathway

Std no.



% Num/Den


% Num/Den


% Num/Den

4.1 [2]

1 OC

A care pathway or bundle for patients with dementia is in place:

Yes 60.8%

121/199 In development

In development

In development 26.1% 52/199

4.2 [2]

1a OC

(If Q1=Yes or In development) A senior clinician is responsible for implementation and/ or review of the care pathway: (y/n)

97.1% 168/173

Yes Yes


Std no.



% Num/Den


% Num/Den


% Num/Den

4.1 [2]

1b OC

(If Q1=Yes or In development) The dementia care pathway/ bundle is integrated within or linked to the following care pathways:

Delirium

Yes 65.9%

114/173 Yes


Pathway in development 26.6% 46/173

Stroke

Yes 32.9% 57/173



Fractured neck of femur

Yes 43.6% 75/172




Staff suggestions for your hospital

Carer comments for your hospital

Carer expectations from the national report

Full list of recommendations from the national report

Staff and carer comments, carer expectations and recommendations


Staff suggestions for your hospital The staff questionnaire asked staff to suggest one way in which their hospital could improve the care provided to patients with dementia. In total, there were 16504 suggestions made by staff in the national sample (there may be more than one suggestion per questionnaire). The Countess of Chester Hospital received 52 suggestions. Hospitals which received fewer than 10 suggestions have not received a breakdown. The breakdown is shown as percentages of the total number of suggestions received. A list of verbatim suggestions for your hospital is in the separate Appendices document.

Staff suggestions: breakdown by theme National

% (Num/Den)

Your hospital %

(Num/Den)

Staffing General comments on better staffing levels Better access to dementia specialist staff including dementia

champions

36% (5939/16504)

29% (15/52)

Environment and activities Better access to activities Better access to space away from bed e.g. garden, day room General comments: making environment ‘dementia friendly’

20% (3298/16504)

37% (19/52)

Training and information More and better training Making training mandatory Training on a specified subject e.g. the Mental Capacity Act

15% (2478/16504)

19% (10/52)

Governance/ hospital operations Less/ no bed moves for patients with dementia Quicker/ better discharge Better integrated working with other services/ organisations

7% (1134/16504)

4% (2/52)

Information and communication of patients’ dementia More/ better use of personal information e.g. ‘This is Me’ Better communication between departments of patients’

dementia

7% (1112/16504)

0% (0/52)

Patient care Better support skills e.g. listening, speaking with patient Better provision for/ response to care needs e.g. pain relief,

toileting, therapy provision

5% (878/16504)

4% (2/52)

Carers/ family Utilise/ actively encourage carers in patient care Open visiting for carers Better facilities for carers in the hospital

5% (804/16504)

6% (3/52)

Patient nutrition and hydration Better access to snacks and finger foods Better/ more food related equipment e.g. adapted cutlery,

coloured crockery, drinking beakers Improved systems including ordering systems and food

charts

5% (783/16504)

2% (1/52)


Carer comments for your hospital The carer questionnaire asked people if they wished to make a comment about any aspects of the care provided by the hospital. In total, there were 10370 coded comments (there may be more than one comment per questionnaire) made by carers in the national sample. The Countess of Chester Hospital received 0 comments. Hospitals who received fewer than 10 comments have not received a breakdown. The breakdown is shown as percentages of the total number of comments received, both at a national and hospital level. Verbatim comments from the carer questionnaire have not been included as carers were not advised these would be published in local reports. Comments have been provided to audit leads separately for them to review and act upon.

Carer comments: breakdown by theme

National: Positive

comments % (Num/Den)

Your hospital: Positive


National: Negative


Your hospital: Negative


Patient care Staff well informed and understood

person with dementia’s needs Quality of care including personal

care, provision of activities, help with food/ drink

Medical care and treatment

12% (1201/10370)

-% (-/-)

23% (2413/10370)

-% (-/-)

Perceptions of staff Staff characteristics e.g. helpful/

unhelpful, caring/ uncaring Positive/ negative effect on the

patient Good/ poor qualities of particular

staffing groups

22% (2242/10370)

-% (-/-)

6% (573/10370)

-% (-/-)

Staffing Levels Understaffed Staff too busy/ overworked

- - 5% (473/10370)

-% (-/-)

Discharge Unsafe/ poor discharge Failed discharge Carer not informed of discharge

- - 5%

(465/10370) -% (-/-)

Environment Ward clean/ dirty

1% (61/10370)

-% (-/-)

1% (134/10370)

-% (-/-)

Support for Carers Carer support Facilities for carers in the hospital

2% (192/10370)

-% (-/-)

1% (114/10370)

-% (-/-)

Other General positive/ negative comment e.g. “brilliant” or “awful”

4% (428/10370)

-% (-/-)

2% (218/10370)

-% (-/-)


Carer expectations from the national report What should carers expect from hospitals when a person with dementia is admitted?

"Carers have a crucial role to play in the care of people with dementia. When a person with dementia develops a physical health problem and/ or their behaviour changes the carer is often the first to be aware of this. If that person is admitted to hospital or a care home it is often the carer who knows the person’s history and is able to provide care staff with crucial information. Carers can also help support communication and share information with the person with dementia. This helps to ensure that the right care and treatment is provided which takes into account additional support needs and preferences.

Carers want a collaborative team approach to care, and to be seen as partners in care. Carers want to be kept involved and informed throughout assessment, treatment and discharge planning for the person they care for.

Carers of people with dementia also have their own needs, which need to be assessed and taken into account. Research shows that carers of older people with dementia experience greater strain and distress than carers of other older people. In addition, many carers of people with dementia are older people themselves, with physical frailty and health conditions of their own.

It is carers who are responsible for care when the professionals aren’t there, and as the condition progresses are commonly faced with co-ordinating and managing complex needs".

Triangle of Care, Carers Trust and the Royal College of Nursing, 2013.

“Carers should be welcomed. They are an essential part of the patient’s team.”

John’s Campaign.

"Carers of people with dementia should be able to spend as much time as necessary with the person, whenever they need to.”

Hospital Care, Alzheimer’s Society.

When a person with dementia goes into hospital, a person who cares for them can expect:

1. To be able to visit at any time to provide care or support whenever this is needed, including overnight.

2. That the nature of their relationship to the person with dementia is respected: the carer's presence is welcome to support good care, but should not be depended on as necessary to provide personal care and support, unless this is their expressed wish.

3. The hospital and staff to recognise the value of carer input to the care of the person with dementia.


4. To receive clear written information from the hospital designed for carers, including: Any times when carers may not be present, e.g. to protect the privacy of the person they are

visiting or other patients Information about how to communicate with staff in the hospital and who to contact Information about any help provided by the hospital e.g. with refreshments, meals or parking.

With the consent of the person with dementia, or as part of a best interests decision making process:

5. To be kept clearly informed about the care and progress of the person with dementia during the hospital stay, including being involved in decisions made about care.

6. To be involved in the discussion about place of discharge and support needs of the person with dementia, including adequate notice of discharge.

7. To receive a copy of the discharge plan.

This should be a written care plan that sets out the support that will be provided to meet the assessed needs of the carer and/ or person with dementia.

8. That the hospital will seek current personal information (as distinct from medical information) to help

provide the best possible care for the person with dementia. This will include details such as the persons preferred name, parts of their life story that they like to talk about (family, pets, work, hobbies), personal preferences (food, drink, how they like to communicate), whether they need help or support with personal care, whether there is anything that is likely to cause distress (e.g. sudden noise) and how to help them if this occurs.

9. That healthcare professionals will have awareness and understanding of the standard of care required by people with dementia, delirium and cognitive impairment admitted to hospital and of the local care pathway or other procedures in place.

10. That the person with dementia is not excluded from therapeutic interventions aimed at improving mobility or cognitive stimulation and that healthcare professionals can accommodate their needs to provide adequate support.

11. That the person with dementia receives adequate support with nutrition and hydration.

12. That appropriate food choices are available for the person with dementia, including finger food, snacks and lighter meal options. The menu should include photos to help them choose.

13. To be appropriately directed to services that can provide further advice and support, including a referral to the local authority for a carer’s assessment. A carer’s assessment from the local council (adult social services department) will determine whether carers are eligible for support. Support could include services provided directly to the carer, or services provided to the person they care for.

14. That carers are represented within the hospital/ Trust Dementia Working Group, and asked regularly to provide anonymous feedback to help improve the quality of care.


Full list of recommendations from the national report National Commissioners should: Propose a nationally backed monitoring programme aimed at embedding the collection, sharing and use

of person centred information. This should include a clear expectation that once gathered, this information will follow the patient between providers, and that this will be monitored.

Clinical Commissioning Groups/ Health Boards should: Specify in contracts with care homes that the personal care story/ information sheet that is completed for

each resident should accompany them on any admission to hospital.

Ensure that tenders let by Trusts for new catering contracts always specify provision of finger foods for main meals and access to a range of snacks 24 hours a day.

Trust Boards/ Council of Governors/ Board of the Health Board should: Request that the information they receive on delayed discharges and patient safety indicators including

falls, pressure ulcers and readmissions can identify the proportion of the patient population with dementia.

The Chief Executive Officer should: Ensure that there is a dementia champion available to support staff 24 hrs per day, 7 days per week. This

could be achieved through ensuring that people in roles such as Site Nurse Practitioners and Bed Managers have expertise in dementia care.

Ensure that carers for people with dementia can communicate with clinicians in order to share and receive information. Carers should be given the opportunity to speak to staff privately, ensuring that their privacy and that of patients is respected.

Ensure that there is an activity program which provides opportunities for social interaction for people with dementia.

Ensure that this report and the local audit report are disseminated to the appropriate staff members (i.e. ward managers, dementia leads etc).

Publish progress made against these recommendations as part of an annual statement on dementia care quality, accessible via the Trust/ Health Board website.

(With the Directors of Medicine and Nursing) monitor support available to staff outside of weekday hours. This should be considered for inclusion in the NHS staff survey as a local question.

Ensure that a Trust dementia lead is nominated to work with teams to: Target, agree and implement local quality improvement initiatives that are aligned to areas of need as

highlighted by the local and national dementia report (2017) findings Agree action plans and deadlines for implementing changes in advance of the next main round of

audit in 2018 Report dementia QI outputs back to the Trust Board.


The Medical Director should: Ensure information on the dementia pathway/ bundle and its links to pathways for other conditions, is

available and accessible to other organisations to facilitate development and discussion.

The Medical Director and Nursing Directors should: Ensure that hospitals have robust mechanisms in place for assessing delirium in people with dementia

including: At admission, a full clinical delirium assessment, whenever indicators of delirium are identified Cognitive tests administered on admission and again before discharge Delirium screening and assessment fully documented in the patients notes (regardless of the

outcome) Care offered in concordance with the delirium evidence-base recommendations when the assessment

indicates symptoms of delirium Results recorded on the electronic discharge summary.

Ensure that structured pain assessments are in use and properly recorded for people with a diagnosis or current history of dementia.

Incorporate a heading for discussions with relatives/ carers within the patient notes/ healthcare records, and ensure staff are aware of its purpose.

Promote the attendance of key carers to support care, but ensure that this is complementary to, and not instead of, care delivered by staff. The level of input by carers, and how carers feel about the level of input they have been asked to deliver should be monitored through carer feedback, complaints and PAL enquiries. Carer satisfaction should be seen as a marker of good care. Ward managers should be supported to ensure carers supporting patients should not be asked to leave at mealtimes and/ or stopped from helping with meals. (This excludes emergency and urgent care and treatment).

Ensure that dementia champions are identified at directorate level as well as ward level.

(With the Education Lead for the Trust or Health Board) ensure that training in dementia awareness is a

priority for all staffing groups. eLearning should not be relied on as the sole medium for delivering training in dementia awareness.

Ensure staff receive training in delirium and its relationship to dementia, manifestations of pain, and behavioural and psychological symptoms.

(With the Head of Therapy Directorate) keep central training records on all staff receiving training in dementia, enabling them to be aware of the levels of awareness and expertise in the hospital.

The Director of Nursing and Head of Therapy Directorate should: Work with dementia and therapy leads to create or enhance activity programs to provide opportunities for

social interaction for people with dementia - especially for patients experiencing longer lengths of stay.


The Director of Nursing should: Incorporate into existing feedback mechanisms survey information from carers on the quality of care for

people with dementia, or collect this information via a biannual carer survey. The NAD tool is recommended as a validated instrument to collect anonymous feedback. The Director of Nursing should report to the Board on the feedback obtained.

The Senior Clinical Lead for Dementia should: Build clear links to the delirium pathway into the dementia pathway, care bundle or protocol.

Ensure that copies of the personal information document (such as Alzheimer’s Society This is Me or other

locally developed document) are available on the ward and that the information is kept accessible to staff and visiting carers.

Work with clinical teams to target local Trust quality improvement initiatives aimed at improving care by

developing and implementing integrated evidence-based care pathways for people with dementia and delirium. These should include: Falls and fractured hips UTIs Chest infections Stroke The overlap and learning from other audits such as the National Audit of Inpatient Falls should be acknowledged and incorporated in this work, and highlighted within staff training.

Target local Trust quality improvement initiatives aimed at ensuring the nutritional needs of people with dementia are met.

Safeguarding and Dignity Leads should: Ensure staff are properly trained and informed on the need for the appropriate presence and participation

of the patient in discussions about the patient’s care, treatment and discharge. Discharge discussions should include a comprehensive note of who was present and the views expressed. The appropriate presence and involvement of the carer(s), as determined by patient consent or best interest decision, should also be recorded.

Ensure that staff are trained in the Mental Capacity Act, including consent, appropriate use of best interests decision making, the use of Lasting Power of Attorney and Advance Decision Making. Training should cover supportive communication with family members/ carers on these topics. (See e.g. NHS England’s Dementia: Good Care Planning).

Ward Managers and Multidisciplinary teams should: Audit implementation/ use of personal information collected to improve care for patients (e.g. This is Me

or other locally developed document). The result of the audit should be fed back to the dementia champions/ dementia lead and ward staff.

Encourage carers to attend mealtimes whenever they want and ensure their input is valued.


Health Education England/ Care Council for Wales should: Incorporate training on delirium and its presentation in people with dementia, including Behavioural and

psychological symptoms of dementia, into Tier 1/ “Informed” level training for healthcare staff.

National Audit of Dementia Project Team should: Consider developing standards on the implementation and frequency of Deprivation of Liberty

Safeguarding orders within acute hospitals.


List of Web Resources

The following documents can be downloaded on the audit website: www.nationalauditofdementia.org.uk

Reports from all rounds of audit

Report on the third round of audit published in July 2017

Report on the second round of audit published in 2013

Report on the first round of audit published in 2011

Standards documents and audit tools from all rounds of audit

Lists of participating Trusts/ Health Boards and hospitals in all rounds of audit

Report from the pilot audit carried out in community hospitals

Comparison between national Round 2 and Round 3 audit data


http://www.nationalauditofdementia.org.uk/

Royal College of Psychiatrists’ Centre for Quality Improvement

21 Prescot Street London E1 8BB

The Royal College of Psychiatrists is a registered charity

in England and Wales (228636) and Scotland (SC038369)

© Healthcare Quality Improvement Partnership Ltd. (HQIP) 2017

www.nationalauditofdementia.org.uk

[email protected]

Documents

National Audit of Dementia Care in General Hospitals … NAD Local Report 3.pdf · National Audit of Dementia Care in General Hospitals 2016-2017 Local report for: The Countess of