Second round of the

National Audit of Dementia

(care in general hospitals)

Standards document

Commissioned by:

© HQIP 2012 1

Foreword and explanatory notes – second round The National Audit of Dementia has been commissioned to run for a second time in 2012.

This is a re-audit to measure progress made in hospital care since the first round of data

collection in 2010.

Participation in the first round of audit was very high, with 99% of Trusts/Health Boards

putting forward one or more hospitals for audit. At the time of writing, 100% of Trust/

Health Boards have registered at least one hospital for Round 2. This creates an excellent

basis for reporting progress locally and nationally.

Updated/new standards in this edition

As this is a re-audit, the standards are largely unchanged. However, we have carried out

necessary updating and replacement to ensure standards remain in line with current

national guidance issued since Round 1 (for example, the 2010 NICE guideline: Delirium:

diagnosis, prevention and management). These standards are marked “updated”.

New standards arising from recommendations made following the first round of audit are

marked “new”.

Audit structure and standards measured in Rounds 1 and 2.

Round 1 of audit consisted of two components:

• A hospital level, “core” audit

• A ward level, “enhanced” audit

The standards compiled for audit therefore included criteria measured at either hospital or

ward level. For Round 2, only hospital-level standards will be measured. In this updated

edition, the standards measured at ward level only have been retained for information and

these are highlighted in red.

© HQIP 2012 2

Foreword to the first round The commissioning of the National Audit of Dementia (care in general hospitals) is an

important milestone that recognises that the treatment of this group of patients in hospital

deserves higher priority. The number of people with dementia is set to rise over the next

decades in tandem with the increasing number of older people and hospitals must be ready

to respond. Indeed it can be said that the treatment of patients with dementia is a “core

business” for the NHS. Those with dementia who are admitted to hospital tend, as a group,

to have poorer outcomes with greater risk of delirium, prolonged length of stay and death.

Yet evidence exists that best practice can reduce these risks. The National Audit will

establish a baseline of service provision as well as acting as a lever for service

improvement.

The aim must be that people with dementia will have access to the best possible care for

the whole range of medical and surgical conditions that they might develop and that

patients and their families will feel confidence in hospital care which acknowledges and is

responsive to individual needs.

This document serves as a compendium of good practice, listing the standards and sources

that are being employed in the audit. They are based on authoritative guidelines and policy

documents, evidence-based whenever possible, and their inclusion has followed extensive

consultation within the organisations sponsoring the audit. As well as acting as a companion

volume for the audit process it is hoped that they will prove useful to all those involved in

improving the care of this often marginalised group of patients.

Peter Crome

Immediate Past President, British Geriatrics Society

Professor of Geriatric Medicine, Keele University

Consultant Geriatrician and Director of Research and Development, North Staffordshire

Combined Healthcare NHS Trust

© HQIP 2012 3

Contents Introduction 4

Standards

Section 1: Assessment 7

Section 2: Access to liaison psychiatry 15

Section 3: Delivery of care 15

Section 4: Governance 17

Section 5: Discharge policy 20

Section 6: Resources supporting people with dementia 23

Section 7: Staff 25

Section 8: Environment 32

Section 9: Information and communication 35

Bibliography 40

© HQIP 2012 4

Introduction Background to the audit In 2006 the Healthcare Commission asked the Royal College of Psychiatrists’ Centre for

Quality Improvement to identify priority areas for audit of the care of people with dementia.

A scoping and consultation exercise identified an audit of care received by people with

dementia in general hospitals as high priority.

Responses to the consultation highlighted that dementia, together with associated needs,

was often overlooked or untreated on admission to hospital, and that admission itself could

have the effect of worsening the effects of dementia. This can result from inevitable

disorientation caused by illness or injury, plus separation from familiar carers, routines and

surroundings, but also from the fact that hospitals may be unprepared to provide services

that meet the particular needs of people with dementia.

The report to the Healthcare Commission recommended the development of an audit which

would:

• collect data on key aspects of care received by people with dementia in hospital;

• examine the ability of hospitals to recognise both the specific needs associated with

dementia (in terms of memory problems and behavioural and psychological

symptoms) and the heightened care need overall.

This is the first national audit in general hospitals of the care of people with dementia.

This audit is funded by the Healthcare Quality Improvement Partnership and is being

managed by a project team based at the Royal College of Psychiatrists’ Centre for Quality

Improvement (CCQI).

The collaborators in this project are the professional bodies for five of the main disciplines

involved in providing dementia services, and one of the main voluntary sector providers of

supports and services:

• the Royal College of Psychiatrists; • the British Geriatrics Society; • the Royal College of Nursing; • the Royal College of Physicians; • the Royal College of General Practitioners; • the Alzheimer’s Society.

© HQIP 2012 5

Development of standards for the National Audit of Dementia (care in general hospitals) A literature review identified source documents for the audit. These included:

• national reports and guidelines (Department of Health, National Audit Office,

National Institute for Health and Clinical Excellence/Social Care Institute for

Excellence);

• standards, guidelines and recommendations issued by professional bodies (Royal

Colleges, the British Geriatrics Society);

• reports and recommendations issued by organisations representing service users and

carers (Alzheimer’s Society, Help the Aged, Age Concern). A secondary review

identified key areas of concern for service users and carers in terms of experience of

care received.

From these sources, a comprehensive manual of standards and criteria was produced with

23 identifiable high level standards or topic areas. These were presented with associated

criteria and linked to their source documents.

The high level standards or topic areas, together with example criteria or measurements,

were presented as a prioritisation/comment exercise for consultation.

The consultation identified priority topics and areas within topics. This was added to

information on national priority and carer/patient priority. A feasibility study examined

which of the criteria identified could be measured within the remit of the audit.

From the measurable criteria, audit tools were produced linked to the standards1. These

were piloted between August and October 2009.

The pilot stage data and feedback from participants led to further amendments to the

standards and audit tools, prior to the rollout of the audit for the first time in March 2010.

The standards presented in this document are therefore those identified as measurable at

this stage. They should not be read as relating to the totality of care received by people

with dementia in every circumstance for which they are admitted to a general hospital.

1 www.nationalauditofdementia.org.uk

© HQIP 2012 6

NB As Round 2 of audit is a repeat of the core (hospital level) audit only, standards

measured only at ward level are not included in this round. These are highlighted in red.

Links to key standard sources will be found in the ‘Reference’ column, which gives a number

linked to the bibliography (p 50).

The questions derived from each standard are shown on the right hand side of the page,

together with a reference to the audit tool (questionnaire) the question is found in and the

question number. Question numbers from Round 1 are shown for cross referencing

purposes.

Classification of standards The classification of the standards is in accordance with the following broad principles:

Type 1: failure to meet these standards 100% would result in a significant threat to patient safety, rights or dignity and/or would breach the law; Type 2: standards that an organisation/ward would be expected to meet in normal practice; Type 3: standards that an organisation/ward should meet to achieve excellent practice.

7 ©HQIP 2012

Audit standards

No.

Type Standard

first round second round

Question/statement Reference Tool Q

no. Tool Q

no.

SECTION 1: Assessment

All people with dementia receive a comprehensive assessment that includes assessment of their mental health needs

1.1 2 There are systems in place to ensure that where dementia is suspected, but not yet diagnosed, this triggers a

OC 18 OC 15 There are systems in place to ensure that where dementia is suspected but not yet diagnosed, this triggers a referral for assessment and differential

43

Key

CA: Casenote audit

OC: Organisational checklist

EC: Environmental checklist (first round only)

WOQ: Ward organisational checklist (first round only)

SQ: Staff questionnaire (first round only)

CPQ1: Carer/Patient questionnaire – part 1 (first round only)

CPQ2: Carer/Patient questionnaire – part 2 (first round only)

Standards not measured in the second round

©HQIP 2012 8

referral for assessment and differential diagnosis, either in the hospital or in the community (via memory service)

diagnosis either in the hospital or in the community (memory services)

1.2 2 Assessment of mental state is carried out in all patients over the age of 65 admitted to hospital. This can be either on admission or immediately prior to admission, in A&E or during pre-admission assessment

OC 19 OC 16 There is a policy or guideline stating that an assessment of mental state is carried out on all patients over the age of 65 admitted to hospital

53

1.3 2 Assessment of mental state includes standardised mental status test e.g. Abbreviated Mental Test (AMT), or Mini Mental State Examination (MMSE)

CA

OC

7

10a6

CA 22 Has a standardised mental status test been carried out?

9

Updated 1.4

2 There are policies or guidelines in place to ensure that patients with dementia or cognitive impairment are assessed for the presence of delirium at presentation

CA

OC

7a

14

CA

OC

23

13

Has an assessment been carried out for recent changes or fluctuation in behaviour that may indicate the presence of delirium? There are policies or guidelines in place to ensure that patients with dementia or cognitive impairment are assessed for the presence of delirium at presentation

9, 41

New 1.5

There are policies or guidelines in place to ensure that patients with dementia or cognitive impairment with behaviour changes suggesting the presence of delirium, are

CA

OC

23a

14

Has the patient been clinically assessed for delirium by a healthcare professional? There are policies or guidelines in place to ensure that patients with

41

©HQIP 2012 9

clinically assessed by a healthcare professional who is trained and competent in the diagnosis of delirium

dementia or cognitive impairment with behaviour changes suggesting the presence of delirium, are clinically assessed by a healthcare professional who is trained and competent in the diagnosis of delirium

1.6 1 A history of mental health or past psychiatric problems is included in the patient history record

CA 1 CA 12 Has the patient’s mental health history been recorded – dementia or other conditions or symptoms?

54

1.7 1 There is a protocol in place governing the use of interventions for violent or challenging behaviour aggression and extreme agitation which is suitable for use in patients with dementia who present with behavioural psychological symptoms (BPSD) (in line with the NICE-SCIE guideline)

CA

CA

CA

CA

OC

11

12

13

14

20

OC

OC

OC

OC

OC

17

17b

17c

17d

17e

There is a protocol in place governing the use of interventions for patients displaying violent or challenging behaviour, aggression and extreme agitation, which is suitable for use in patients who present behavioural psychological symptoms of dementia (BPSD) (in line with the NICE guidance) The protocol specifies consideration of physical causes which may cause challenging behaviour in people with dementia The protocol considers environmental factors such as noise, lack of activity, disorientation The protocol specifies the possibility of using techniques of reassurance, de-escalation, distraction The protocol specifies the risks that must be assessed and taken into

43

©HQIP 2012 10

OC

17f

account before any use of restraint or sedation in people with dementia and the frail elderly The protocol specifies any prescription and administration of antipsychotic drugs is in line with NICE guidance

1.8 1 The protocol specifies the precautions and risk assessments for any use of restraint or sedation in people with dementia and the frail elderly

OC 20b OC 17a The protocol specifies that restraint and sedation is used only as a final option

43

Multidisciplinary assessment 1.9 1 Multidisciplinary assessment

includes: • problem list • co morbid conditions • full record of current

medications and past relevant medications

• assessment of mobility • assessment of nutritional

status, recording of weight and height/BMI

• identification of any help needed with eating and drinking

• whether referral is needed for specialist input, e.g. dietetics

CA

CA

CA

CA

CA

CA

CA

OC

OC

OC

OC

2

2a

2b

2c

2d

2e

36

10

10a1

10a2

10a3

CA

CA

CA

CA

CA

CA

13

14

15

16

17

17a

The multidisciplinary assessment includes problem list The multidisciplinary assessment includes comorbid conditions The assessment includes a record of current medication, including dosage and frequency An assessment of mobility was performed by a healthcare professional An assessment of nutritional status was performed by a healthcare professional The assessment of nutritional status includes recording of BMI (Body Mass Index)/weight

9

©HQIP 2012 11

OC

OC

OC

OC

10a4

10a5

11

12

OC

OC

9

10

Multidisciplinary assessment includes: a) Problem list b) Comorbid conditions c) Current medications including dosages and frequencies d) Assessment of functioning using a standardised instrument – i.e. basic activities of daily living, instrumental activities of daily living, mobility e) Assessment of mental state using a standardised instrument – i.e. mental status (cognitive) testing f) Nutritional status As part of the initial assessment, the patient’s BMI (Body Mass Index) or weight is recorded, wherever possible

1.10 1 A formal pressure sore risk assessment is carried out (e.g. Waterlow, Norton scales) and score recorded

CA 3 CA 18 Has a formal pressure sore risk assessment been carried out and score recorded?

9

1.11 1 As part of their assessment, patients with dementia are asked about the presence and severity of any pain and this is recorded

CA 5 CA 20 As part of the muldisciplinary assessment has the patient been asked about the presence of any pain?

9

1.12 1 As part of their assessment, patients with dementia are asked about continence needs, and this is recorded

CA 4 CA 19 As part of the muldisciplinary assessment has the patient been asked about any continence needs?

9

©HQIP 2012 12

1.13 1 An assessment of functioning using a standardised assessment tool is carried out, e.g. Barthel ADL Functioning Assessment Scale

CA 6 CA 21 Has an assessment of functioning, using a standardised assessment, been carried out?

9

1.14 1 The care assessment contains a section dedicated to collecting information from carer, next of kin or a person who knows the person with dementia well. This includes information relating to the person’s needs while in hospital, such as: • personal details such as

preferred name • routines and preferences • whether the person needs

reminders or support with personal care

• recurring factors that may cause or exacerbate distress

• support or actions that can calm the person if they are agitated

CA

CA

CA

CA

CA

OC

OC

OC

OC

OC

SQ

CPQ1

CPQ1

CPQ2

9

9a

9b

9c

9d

25

26

26b

26c

27 7 4 5

14

CA

CA

CA

CA

CA

OC

OC

25

25a

25b

25c

25d

23

23a1

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? Has information been collected about the patient regarding personal details, preferences and routines? Has information been collected about the patient regarding reminders or support with personal care? Has information been collected about the patient regarding recurring factors that may exacerbate distress? Has information been collected about the patient regarding support or actions that can calm the person if they are agitated? There is a formal system (pro-forma or template) in place for gathering information pertinent to caring for a person with dementia Information collected by the pro-forma includes personal details, preferences and routines

43

©HQIP 2012 13

OC

OC

OC

OC

23a2

23a3

23a4

23b

Information collected by the pro-forma includes reminders or support with personal care Information collected by the pro-forma includes recurring factors that may cause of exacerbate distress Information collected by the pro-forma includes support or actions that can calm the person if they are agitated The form prompts staff to approach carers or relatives to collate necessary information

1.15 3 Information collected as part of the assessment also includes life details which aid communication for staff and integrity for the person with dementia, e.g. family situation, interests and past or current occupation

CA 9e OC

CN

23a5

25e

Information collected by the pro-forma includes life details which aid communication Has information been collected about the patient regarding life details which aid communication?

5, 43

Social and Environmental Assessment This includes:

CA

CA

CA

24

24a

24b

Social and Environmental Assessment Has a need for care assessment by a social worker been identified? Has a care assessment by a social worker been requested? Has a care assessment by a social worker been carried out?

1.16 2 support provided “informally”, i.e. from friends, relatives,

CA

8

CA

24b1

Did the assessment include an assessment of support provided to the

9

©HQIP 2012 14

neighbours or support groups and organisations

OC

10b

OC

11a

person ‘informally’? Social and environmental assessment includes support provided to the person ‘informally’

1.17 2 formal care provision CA

OC

8a

10b

CA

OC

24b2

11b

Did the assessment include a formal care provision? Social and environmental assessment includes care provision assessment

9

1.18 3 financial support assessment CA

OC

8b

10b

CA

OC

24b3

11c

Did the assessment include a financial support? Social and environmental assessment includes financial support assessment

9

1.19 2 home safety assessment, e.g. information requested from patient, relative, carer or GP regarding environmental risk factors; request for Occupational Therapy assessment follow up if required

CA

OC

8c

10c

CA

OC

24b4

11d

Did the assessment include a home safety? Social and environmental assessment includes home safety assessment

9

Care/management plan 1.20 1 People with dementia have a

management plan for any medical condition

CA

2f 43

1.21 1 People with dementia have a nursing management plan for the dementia or symptoms of dementia, or “confusional state”

CA

2g 43

©HQIP 2012 15

SECTION 2: Access to liaison psychiatry

2.1 2 There is a psychiatric liaison service commissioned to provide emergency/urgent assessment and treatment to adults throughout the hospital, including older people

CA

CA

CA

OC

OC

OC

OC

29

31

32

47

47a

47b

48

OC

OC

42

43

The hospital provides access to a liaison psychiatry service which can provide assessment and treatment to adults throughout the hospital The liaison service provides emergency/urgent assessment

54

2.2 2 There is a named Psychiatrist for consultation/liaison

OC 49 OC 44 There is a named Consultant Psychiatrist

54

2.3 2 The Consultant Psychiatrist has dedicated time in his/her job plan

OC 49a OC 44a The Consultant Psychiatrist has dedicated time in his/her job plan for the provision of this service

54

2.4 2 The Consultant Psychiatrist specialises in the care and treatment of older people

OC 49b OC 44b The Consultant Psychiatrist specialises in the care and treatment of older people

54

2.5 2 All liaison practitioners have protected time to perform consultation liaison duties

OC 50c OC 45d Do all healthcare professionals who are part of the liaison psychiatry service have dedicated time?

54

SECTION 3: Delivery of care

Continuity of care 3.1 3 The number of moves within

the hospital or between care settings is kept to a minimum and any moves are undertaken to benefit the person with dementia

CA

OC

OC

15

24

24a

OC 22a The transfer policy specifies that: People with dementia should be moved only for reasons pertaining to their care and treatment

22

©HQIP 2012 16

3.2 3 Any unplanned moves take place for urgent medical reasons which are documented

CA

CA

16

16a

22

3.3 3 Planned moves take place during the daytime

CA

OC

15a

24b

OC

OC

20a

22b

The discharge policy specifies that: Discharge should take place during the day The transfer policy specifies that: The move should take place during the day

22

3.4 3 The patient and their carer/ relative is given notice of and an explanation about planned moves

OC

CPQ1

24c 8

OC

OC

20b

22c

The discharge policy specifies that: Relatives and carers should be informed and updated about the prospective discharge date The transfer policy specifies that: Relatives and carers should be kept informed of any moves within the hospital

22

End of life care 3.5 2 The care pathway for people

with dementia interfaces with both the palliative care pathway and the end of life care pathway to ensure that people with dementia have equal access to palliative and end of life care

OC

OC

15

16

OC 1a The care pathway is adaptable for use within or fitted to the following existing care pathways: a) Acute

b) Palliative

c) End of life

43

3.6 2 The end of life care pathway specifies that the health care team and consultant discuss any issues to do with end of life care with the patient and carers or relatives (including resuscitation and any advance

OC 17 43

©HQIP 2012 17

decisions made by the person with dementia)

Nutrition Updated

3.7 1 Protected mealtimes are in

operation in all wards that admit adults with known or suspected dementia

OC

WOQ

13

16

OC

OC

12

12a

Protected mealtimes are established in all wards that admit adults with known or suspected dementia Ward’s adherence to protected mealtimes is reviewed and monitored

1

3.8 1 The protected mealtime system allows for carers to visit during mealtimes

WOQ 17 1, 5

3.9 2 There is a system in place to ensure all staff are aware of patients who have difficulties at mealtimes

WOQ

SQ

CPQ2

CPQ2

18

12 8 9

1

3.10 2 Staff are encouraged to report patients missing meals to NPSA via the national reporting and learning system

WOQ

SQ

20

14

44

3.11 2 Food is available to patients between mealtimes

WOQ

SQ

22

13

31

SECTION 4: Governance

4.1 2 There is a care pathway for people with dementia

OC 1 OC 1 A care pathway for patients with dementia is in place

30

4.2 2 A senior clinician is responsible for the implementation and review of the care pathway

OC 1a OC 1b A senior clinician is responsible for implementation and/or review of the care pathway

30

©HQIP 2012 18

4.3 1 There is a named officer with designated responsibility for the protection of vulnerable adults

OC 2 OC 2 There is a named officer with designated responsibility for the protection of vulnerable adults

36

4.4 2 The Executive Board regularly reviews the number of in-hospital falls and the breakdown of the immediate causes, and people with dementia can be identified within this number

OC 4 OC 4 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

24

4.5 2 There is a mechanism for the Executive Board to receive regular feedback from the following: • The Clinical Leaders for

older people and people with dementia including Modern Matrons/Nurse Consultants

• Complaints – analysed by age

• PALS – in relation to the services for older people and people with dementia

• Patient Forums or Local Involvement Networks – in relation to the services for older people and people with dementia

OC

OC

OC

OC

OC

5

5a

5b

5c

5d

OC

5

The Executive Board regularly receives feedback from the following: a) The Clinical Leaders for older people and people with dementia including Modern Matrons/Nurse Consultants b) Complaints – analysed by age c) Patient Advice and Liaison Services (PALS) – in relation to the services for older people and people with dementia d) Patient Forums or Local Involvement Networks – in relation to services for older people and people with dementia

24

4.6 2 The hospital has a reporting mechanism to gather information on maximum response time to obtain specialist assessments in the following situations:

OC

OC

OC

9

9a

9b

24

©HQIP 2012 19

• Access to an older people’s multidisciplinary team in A&E/MAU

• Access to an older people’s multidisciplinary team in non-elderly care wards

• Access to an older people’s multidisciplinary team for older people with mental health problems

OC 9c

4.7 2 The Executive Board regularly reviews information collected on: • readmission of patients

with dementia; • delayed transfers of people

with dementia.

OC

OC

OC

3

3a

3b

OC

3

The executive board regularly reviews information collected on: a) Re-admissions, in which patients with dementia can be identified in the total number of patients readmitted b) Delayed discharge/transfers, in which patients with dementia can be identified in the total number of patients with delayed discharge/transfers

22

4.8 2 There is a process in place to review hospital discharge policy and procedures as they relate to people with dementia

OC 6 OC 6 There is a process in place to regularly review hospital discharge policy and procedures, as they relate to people with dementia

22

4.9 2 There is a process for nursing staff to record and report risks to patient care if they believe ward staffing is inadequate

OC

SQ

7

16

OC 7 Nursing staff have access to a recognised process to record and report risks to patient care if they believe ward staffing is inadequate

4, 50

4.10 3 Audit (within the hospital) includes percentage of people with suspected dementia for whom structural imaging, computed tomography (CT), scanning or magnetic

OC 8 42

©HQIP 2012 20

resonance imaging (MRI) has been undertaken as part of assessment and diagnosis

new 4.11

Staff are supported by identified clinical leads for dementia, e.g. dementia specialists/nurses, mental health liaison, dementia champions

OC 8 There are champions for dementia at: a) Directorate level b) Ward level

49

SECTION 5: Discharge policy

5.1 2 There is a discharge policy which specifies that discharge is an actively managed process which begins within 24 hours of admission

CA

OC

17

22

CA

OC

39

19

Was discharge planning initiated within 24 hours of admission? The discharge policy states that discharge should be an actively managed process which begins within 24 hours of admission

22, 39

5.2 2 Information about discharge and support is made available to patients and their relatives on admission and this is recorded, e.g. a leaflet summarising information, in plain English or other appropriate language

CA

OC

10

23

CA

OC

OC

OC

26

21

21a

21b

Has information about support on discharge been given to the patient and/or the carer? Information about discharge and support (written in plain English or Welsh, and available in other appropriate languages) is made available to patients and their relatives The discharge policy specifies that this information is made available to patients and their relatives on admission The written information about discharge provided to patients and relatives contains information about

39

©HQIP 2012 21

organisations representing people with dementia and carers

Updated 5.3

2 There is a section or prompt in the general hospital discharge summary for mental health diagnosis and management This includes the following: • the patients level of

cognitive ability • the cause of cognitive

impairment • whether there are or have

been symptoms of delirium

• the presence of persistent behavioural and psychiatric symptoms of dementia to a degree which requires specialist dementia care or needs to be addressed

• antipsychotics or other medication prescribed for mental health needs

CA

CA

CA

CA

CA

CA

CA

OC

18

18a

18b

19

20

21

35

21

CA

CA

CA

CA

CA

CA

OC

30

31

31a

32

32a

33

18

At the point of discharge, the following information was summarised and recorded: a) The patient’s level of cognitive impairment using a standardised assessment b) The cause of cognitive impairment Have there been any symptoms of delirium? Have the symptoms of delirium been summarised for discharge? Have there been any persistent behavioural and psychiatric symptoms of dementia (wandering, aggression, shouting) during this admission? Have the symptoms of behavioural and psychiatric symptoms of dementia been summarised for discharge? Is there a record in the discharge summary/notes that there is a prescription of antipsychotics that is being continued post discharge? There is a section or prompt in the general hospital discharge summary for mental health diagnosis and management

7, 54

©HQIP 2012 22

5.4 1 The discharge co-ordinator/ person planning discharge discusses (or receives information about) the appropriate place of discharge and support needs with: • the person with dementia • the persons carer or

relative • the medical consultant

responsible for the patients care

• other members of the MDT

CA

CA

CA

CA

CA

OC

CPQ1

CPQ1

CPQ2

CPQ2

23

23a

23b

23c

23d

31c

11

13

23

24

CA

OC

35

28

Is there evidence in the notes that the discharge coordinator/person planning discharge has discussed appropriate place of discharge and support needs with: a) The person with dementia b) The person’s carer/relative c) The consultant responsible for the patient’s care d) Other members of the multidisciplinary team There are clear guidelines regarding involvement of carers and information sharing. This includes: c) Asking the carer about their wishes and ability to provide care and support of the person with dementia post discharge

22

5.5 2 In advance of discharge, carers are offered an assessment of their current needs

CA

CPQ1

28

12

CA 41 An assessment of the carer’s current needs has taken place in advance of discharge

43

5.6 1 In advance of discharge, patient information is complied into a single, up-to-date, discharge plan.

CA 24 CA 36 Has a single plan for discharge with clear updated information been produced?

54

5.7 2 The discharge plan contains the following: • up to date physical and

mental health assessment

CA 26 CA 37 Are any support needs that have been identified documented in the discharge plan or summary?

39

©HQIP 2012 23

information • details of onward referrals

and support needs • details of changes in

social circumstances 5.8 1 A copy of the discharge plan is

provided to the patient and/or carer and this is recorded

CA

CPQ1

25

17

CA 38 Has the patient and/or carer received a copy of the plan or summary?

39

5.10 2 Carers or family receive advance notice of discharge (at least 24 hours) and this is documented

CA

CPQ1

27

16

CA 40 Carers of family have received notice of discharge and this is documented

5, 22

SECTION 6: Resources supporting people with dementia

6.1 2 Multidisciplinary teams supporting people with dementia include: • a senior specialist

physician in medical care of older people

• a co-ordinating specialist nurse with experience in supporting people with dementia or older people

• a senior social worker or a specialist nurse who is also a care manager with direct access to care services

• other

9

6.2 2 The hospital has access to intermediate care services which will admit people with dementia

OC 40 OC 35 The hospital has access to intermediate care services, which will admit people with dementia

30

6.3 3 Access to intermediate care allows people with dementia to be admitted to intermediate

OC 40a OC 35a Access to intermediate care services allows people with dementia to be admitted to intermediate care directly

24

©HQIP 2012 24

care directly and avoid unnecessary hospital admission

and avoid unnecessary hospital admission

6.4 2 There is/are a named person (s) with overall responsibility in their role for discharge coordination for people with dementia The person in this role provides consultation, advice and support for staff carrying out discharge coordination

CA

OC

22

42

CA

OC

34

37

Did a named person coordinate the discharge plan? There is a named person who takes overall responsibility for complex needs discharge and this includes people with dementia

22

6.5 2 The named person(s) responsible for discharge coordination has/have training in ongoing needs of people with dementia

OC 42a OC 37a This person has training in ongoing needs of people with dementia

22

6.6 3 The named person(s) responsible for discharge coordination has/have experience of working with people with dementia and their carers

OC 42b OC 37b This person has experience of working with people with dementia and their carers

22

6.7 2 There is a named person who has responsibility in their job role to advise carers/relatives on a range of matters, such as: problems getting to and from hospital; benefits; residential and nursing care; help at home; difficulties for carers/ relatives such as illness, disability, stress or other commitments that may affect their ability to visit or to continue to care

OC 43 OC 38 There is a social worker or other designated person responsible for working with people with dementia and their carers, and providing advice and support, or directing to appropriate organisations or agencies

5

©HQIP 2012 25

6.8 1 There is access to specialist assessment and advice concerning swallowing and feeding in dementia

OC 44 OC 39 There is access to specialist assessment and advice on helping patients with dementia in their swallowing and eating

43

6.9 3 There is access to an interpreting service which meets the needs of people with dementia

OC 45 OC 40 There is access to an interpreting service which meets the needs of people with dementia in the hospital

43

6.10 2 There is access to advocacy services that have experience and training in working with people with dementia

OC 46 OC 41 There is access to advocacy services with experience and training in working with people with dementia

43

6.11 3 There are opportunities for social interaction for patients with dementia e.g. to eat/ socialise away from their bed area with other patients

WOQ 21 4

SECTION 7: Staff

Training, Learning and Development

7.1 2 There is a named dignity lead to provide guidance, advice and consultation to staff

OC

SQ

CPQ2

41

17

12

OC 36 There is a named dignity lead to provide guidance, advice and consultation to staff

25

7.2 2 There is a training and knowledge framework or strategy that identifies necessary skill development in working with and caring for people with dementia

OC

SQ

SQ

CPQ2

33

1b

4i 5

OC 29 There is a training and knowledge framework or strategy that identifies necessary skill development in working with and caring for people with dementia

43

7.3 2 Training in skill development OC 34 The following questions are about 35, 43, 47, 55

©HQIP 2012 26

for dementia is available to staff and includes: • Principles of person centred

care • Communication including

non-verbal communication • The role of other services

and referral processes • Introduction to adult

protection policy and procedures

• Anticipating, avoiding and managing challenging behaviour, including de-escalation and distraction techniques and methods of physical restraint

• Risks of use of restraints or sedation in older/ vulnerable adults

• Palliative care approaches • Assessing cognitive ability • Mental Capacity Act training

OC

SQ

SQ

SQ

SQ

SQ

SQ

SQ

SQ

SQ

SQ

SQ

SQ

SQ

SQ

35

1a

1c

1d

1e

1f

1g

1h

1l

1m

4a

4c

4d

4e

4g

OC

OC

32d

32e

training that is provided to acute healthcare staff who are involved in the care of people with dementia (or suspected dementia): Communication skills specific for people with dementia: Response options for each job role: Included in the Trust training programme in the last 12 months; Made available via external provision in the last 12 months; Not available in the last 12 months • Doctors • Nurses • HCAs

Approaches to behaviour that challenges including management of aggression and extreme agitation: Response options for each job role: Included in the Trust training programme in the last 12 months; Made available via external provision in the last 12 months; Not available in the last 12 months • Doctors • Nurses • HCAs

7.4 2 Dementia awareness training relating to the care provision, systems, information and resources available in the

OC

OC

32

32a (a1-

OC

30

Staff induction programmes include dementia awareness The following questions are about

43, 47

©HQIP 2012 27

hospital is mandatory for all acute healthcare staff involved in the care of people with dementia or who may have dementia

SQ

SQ

SQ

a7)

1i

4a

4b

OC

31

training that is provided to acute healthcare staff who are involved in the care of people with dementia (or suspected dementia): Dementia awareness training: Response options for each job role: Mandatory; Provided in induction; Provided in the last 12 months; Not provided in the last 12 months • Doctors • Nurses • HCAs • Other allied healthcare

professionals, e.g. physiotherapists, dietician

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

7.5 3 Dementia awareness training is provided to other healthcare staff

Same as above 43

7.6 1 All staff working with people with dementia have training in the protection of vulnerable adults

OC 36

OC

32a

The following questions are about training that is provided to acute healthcare staff who are involved in the care of people with dementia (or suspected dementia): Protection of vulnerable adults: Response options for each job role: Included in the Trust training programme in the last 12 months; Made available via external provision in the last 12 months; Not available in the last 12 months • Doctors

43

©HQIP 2012 28

• Nurses • HCAs

7.7 2 All staff working with people

with dementia and older adults have awareness of how to support patients with hearing/ visual impairments

OC

SQ

37

1j

OC

32b

The following questions are about training that is provided to acute healthcare staff who are involved in the care of people with dementia (or suspected dementia): How to support patients with hearing/visual impairments: Response options for each job role: Included in the Trust training programme in the last 12 months; Made available via external provision in the last 12 months; Not available in the last 12 months • Doctors • Nurses • HCAs

55

7.8 2 All staff working with people with dementia receive basic training in understanding the Mental Capacity Act

OC

38

OC

32c

The following questions are about training that is provided to acute healthcare staff who are involved in the care of people with dementia (or suspected dementia): Mental Capacity Act: Response options for each job role: Included in the Trust training programme in the last 12 months; Made available via external provision in the last 12 months; Not available in the last 12 months • Doctors • Nurses • HCAs

55

©HQIP 2012 29

7.9 1 All staff working with people with dementia who carry out assessments of capacity receive training in the MCA and assessment and Deprivation of Liberty safeguards

SQ 4f 55

7.10 3 Liaison teams from local mental health and learning disability services offer regular consultation and training for healthcare professionals in the hospital who provide care for people with dementia

OC 51 OC 34 Liaison teams from local mental health and learning disability services offer regular training for healthcare professionals in the hospital who provide care for people with dementia

54

7.11 3 Involvement of people with dementia and carers, and use of their experiences is included in the training for ward staff This could be a presentation from a person with dementia and carer, use of patient/carer diaries, use of feedback from questionnaires, audits and complaints relating to people with dementia

OC

SQ

CPQ2

39

1k

22

OC 33 Involvement of people with dementia and carers and use of their experiences is included in the training for ward staff

54

7.12 1 Wards that admit people with dementia provide staff with systems for supporting staff development in dementia care including appraisal and mentorship, clinical supervision and access to ethical guidance, access to reflective practice groups

WOQ

WOQ

WOQ

WOQ

WOQ

11

11a

11b

11c

12

35

©HQIP 2012 30

SQ 18 7.13 2 There are arrangements for

staff cover to allow staff to attend training relating to the care of people with dementia

WOQ

SQ

10 3

55

Staffing on wards admitting people with dementia

7.14 1 The ward has an agreed minimum staffing level across all shifts, which is met

WOQ 8 55

7.15 1 The skill mix ratio on the ward meets or exceeds national benchmark

WOQ WOQ

WOQ

WOQ

1 2 3 4

50, 55

7.16 2 There are systems in place that ensure that all factors that affect staff levels and skill mix are reviewed on a daily basis taking account of: • sickness and absence • training • supervision • need for one-one care

provision

WOQ

SQ

SQ

SQ

CPQ1

CPQ2

CPQ2

CPQ2

CPQ2

CPQ2

9

5c

5d

5e 2

10

10a

10b

10d

10e

61

©HQIP 2012 31

CPQ2

CPQ2

18

19 7.17 2 There is a system to routinely

monitor and report on the use of bank and agency staff

WOQ 6 55

7.18 1 There is a system to ensure that staffing levels are sufficient at mealtimes to aid people with dementia to eat and to choose food if necessary

WOQ

CPQ2

19

10c

1, 5

7.19 2 Wards that admit patients with dementia are able to access the following professionals/services: • Physicians specialising in

care of older people • Nursing staff specialising

in care of older people • Liaison psychiatry • Pharmacy • Occupational Therapy • Social Work • Physiotherapy • Dietetics • Speech and language

therapy • Psychology/

neuropsychology • Specialist infection control

services • Tissue viability services • Specialist continence

services

WOQ

SQ

14 (a1-l2)

19

55

7.20 3 There is access to faith specific WOQ 13 55

©HQIP 2012 32

support provided by someone with an understanding of dementia

7.21 2 The available administrative support meets the needs of the ward

WOQ 7 55

SECTION 8: Environment

Physical environment on the ward

8.1 2 Patients with dementia are situated on the ward where they are visible to staff and staff are visible to them

EC 9 35

Orientation 8.2 3 Colour schemes are used to

help patients with dementia to find their way around the ward e.g. doors and bays are painted in a different colour

EC 1 37

8.3 2 Signs and maps use large and clear (easy to read) fonts and colours

EC

3 31, 37

8.4 2 Information (words and pictures) on signs is in clear contrast to the background

EC 4 37

8.5 2 Key areas are clearly marked e.g. the nursing station, the bathrooms/toilets, any side rooms or waiting areas

EC

CPQ2

2 1

8

8.6 3 All patients with dementia are able to see a clock from their bed

EC 10 45

8.7 2 All patients with dementia are able to see a calendar (or

EC 11 45

©HQIP 2012 33

orientation board) from their bed

8.8 2 Signs to locate the toilet are visible from the patient’s bed

EC 14 8

Bed area 8.9 3 For patients with dementia,

messages from relatives and personal objects including self care items are situated where the patient can see them at all times

EC

CPQ2

12 3

38

Private/rest areas 8.10 3 A room/area is available for

patients to use for a break from the ward environment e.g a patient lounge, “quiet” room, seating area

EC 13 5

Bathroom 8.11 2 Toilet and bathroom doors

carry signs and are a different colour to the walls

EC

EC

15

16

37

8.12 2 Items such as the soap dispenser, the bin, the hand dryer are clearly labeled with pictures as well as words so that the patient can identify them

EC 17 37

8.13 1 There are call/alarm buttons visible in the toilet/bathroom

EC 25

8.14 1 There are hand rails, large handles and a raised toilet seat to support the patients

EC 18 45

8.15 3 Door handles are a different colour to the wall so that they stand out

EC 19 37

©HQIP 2012 34

8.16 3 Toilet paper is a different colour to the wall so that it stands out

EC 20 37

8.17 1 The toilets are big enough for assisted toileting

EC 21 8

8.18 1 The bathroom is big enough for assisted bathing

EC 22 8, 31

8.19 1 Single sex toilet/washing facilities are provided for patient use

EC 23 31

8.20 1 Facilities are available so that patients have choices about bathing or assisted bathing, e.g. at the sink, overhead showering, hand held shower head, full bath

EC 24

Promoting independence 8.21 2 There is space for restless

patients with dementia to walk up and down where they are visible to staff

EC 26 21, 35

8.22 2 The ward is adapted to assist people with mobility difficulties, e.g. large handles, hand rails

EC

CPQ2

27

11

45

8.23 2 The ward is able to provide adapted utensils to encourage patients to assist themselves with their meals and eat independently

EC 30 31

8.24 2 The ward can readily provide equipment to assist mobility, e.g. walking frames, wheelchairs

EC 28 43

8.25 2 The ward can readily provide EC 29 31

©HQIP 2012 35

hearing aids such as amplifiers/ communicators/hearing loops/batteries for personal aids or other assistive devices

Floor 8.26 1 Level changes and contrasts

(gentle slopes and steps) are clearly marked

EC 5 37

8.27 2 Floors are plain or subtly patterned, not “busy”, e.g without bold or high contrast design or pattern which could affect orientation

EC 6 8, 37

8.28 2 Floor surfaces are subtly polished rather than high gloss

EC 7 37

8.29 2 Floor surfaces are non slip EC 8 37

SECTION 9: Information and communication

9.1 2 The name that the person with dementia prefers to be addressed by is recorded and communicated to all staff that work with them

WOQ

CPQ2

24

15

5

9.2 2 There is a system to ensure that other personal information (such as routines, preferences, support needed with personal care) is conveyed to staff involved in the patients care in order to improve the type and level of care they receive, e.g. times of day when more support is needed, ability to

WOQ

SQ

SQ

CPQ2

CPQ2

25 8

15 6 7

5, 43

©HQIP 2012 36

eat/drink unprompted or unaided

CPQ2

CPQ2

CPQ2

CPQ2

CPQ2

CPQ2

9

10

10a

10b

10d

10e 9.3 1 There is a system to ensure

that staff directly involved in caring for/treating the person with dementia are informed about any effect of the dementia on the persons behaviour and communication, e.g. ability to answer queries about health accurately or to follow instructions, or other behavioural/psychological symptoms, such as agitation or hallucination

OC

WOQ

SQ

CPQ2

28

26 6 4

OC 24 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

5, 43

9.4 2 There is a system for communicating to other staff any effect of the dementia on the persons behaviour and communication, e.g. whenever the person with dementia accesses other areas outside their ward for assessment or other treatment

OC

WOQ

28

27

OC 25 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

5, 43

9.5 2 Patients and/or carers are able to convey information relating

SQ

5a

43

©HQIP 2012 37

to care and treatment in a confidential manner

CPQ1

CPQ2

6

13 9.6 2 The ward ensures that a

healthcare professional responsible for coordinating the person’s care is identified to the person and carers/ relatives

WOQ

SQ

CPQ1

23

10 1

5

9.7 2 Staff explain changes in care and treatment to people with dementia and/or their carers and provide regular updates on progress

SQ

CPQ1

CPQ2

5b 3

21

5

9.8 1 Patients and carers/relatives are given information about the ward and hospital routines: mealtimes, visiting hours, periods of rest/quiet and the local complaints procedure

WOQ

WOQ

SQ

CPQ2

CPQ2

15a

15b

11

16

17

5

9.9 3 Information about common medical conditions and surgical procedures is available in a dementia-friendly format and backed with verbal discussion as necessary

CPQ2 20

9.10 2 The patient’s notes are organised in such a way that it is easy to identify any

CA

CA

41

42

CA

46

Is information about the person’s dementia quickly found in a specified place in the file?

©HQIP 2012 38

communication or memory problems and related care and support needs

OC

OC

OC

29

29a

29b

CA

OC

47

26

Is information about related care and support needs quickly found in a specified place in the file? The patient's notes are organised in such a way that it is easy to: a) Identify any communication or memory problems b) See the care plan

9.11 2 Carers or relatives are asked about the extent to which they prefer to be involved in the care of the person with dementia while on the ward, e.g. help with personal care or at mealtimes, looking after clothing, spectacles or hearing aids, enjoyable pastimes

OC

CPQ1

31b 9

OC 28 There are clear guidelines regarding involvement of carers and information sharing. This includes: b) Asking the carer about the extent they prefer to be involved with the care and support of the person with dementia whilst in the hospital

5

9.12 2 Information about carers assessment is available on wards

WOQ 15d 5

9.13 2 There is a system in place to ensure that carers are advised about obtaining carer’s assessment and support, e.g. wards can provide information about who to approach in the hospital for further information and assistance

OC

SQ

CPQ1

CPQ1

CPQ1

30

4h

10

14

15

OC 27 There is a system in place to ensure that carers are advised about obtaining carer’s assessment and support

5

9.14 2 There are clear guidelines regarding involvement of carers and what information is

OC

WOQ

31a

15c

OC 28 There are clear guidelines regarding involvement of carers and information sharing. This includes:

5

©HQIP 2012 39

to be shared with them and this is communicated to carers

SQ

CPQ1

9 7

a) Making sure the carer knows what information will be shared with them

40

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Care needs of ethnic older people suffering from Alzheimer’s. PRIAE, Leeds. http://www.priae.org/docs/PRIAE%20Summary%20Briefing%20-CNEOPSA.doc

47. Royal College of Nursing (2008) Response to the National Dementia Strategy Consultation.

http://www.rcn.org.uk/__data/assets/pdf_file/0010/282493/2009_National_Dialogue_on_Dementia.pdf

48. Royal College of Nursing (2009) Breaking down barriers, driving up standards. The role of the

ward sister and charge nurse. Royal College of Nursing, London. http://www.rcn.org.uk/__data/assets/pdf_file/0009/287784/003312.pdf

49. Royal College of Nursing (accessed March 2012). Commitment to the care of people with

dementia in general hospitals. http://www.rcn.org.uk/development/practice/dementia/commitment_to_the_care_of_people_with_dementia_in_general_hospitals/commitment_to_dementia

50. Royal College of Nursing Policy Unit (2006) Setting Appropriate Ward Nurse Staffing Levels in

NHS Acute Trusts. Principles for Appropriate Ward Nurse Staffing. Royal College of Nursing, London. http://www.rcn.org.uk/__data/assets/pdf_file/0007/287710/setting_appropriate_ward_nurse_staffing_levels_in_nhs_acut.pdf

51. Royal College of Physicians (2004) Acute Medicine: Making it work for patients. Chapter 7.

Royal College of Physicians, London. http://old.rcplondon.ac.uk/pubs/books/AcuteMedicine/AcuteMedicineFull.pdf

52. Royal College of Physicians (2007) Acute Medical Care. The right person in the right setting -

first time. Royal College of Physicians, London. http://bookshop.rcplondon.ac.uk/contents/pub235-b42eb97d-209b-4ecd-9127-ef95cc21c819.pdf

©HQIP 2012 44

53. Royal College of Physicians/British Geriatrics Society (2006) Guidelines for the prevention, diagnosis and management of delirium in older people in hospital. http://www.bgs.org.uk/index.php?option=com_content&view=article&id=170%3Aclinguidedeliriumtreatment&catid=42%3Acatclinguidelines&Itemid=107&showall=1

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SCIE, London. http://www.scie.org.uk/publications/guides/guide15/files/guide15.pdf 57. University of Leeds (2002) Between Two Stools: Psychiatric services for older people in general

hospitals. Report of a UK survey. University of Leeds, Leeds. http://www.leeds.ac.uk/lpop/documents/betweentwostools.pdf

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Chloë Hood Programme Manager Aarti Gandesha Deputy Manager 020 7977 4975 020 7977 4976

chood@cru.rcpsych.ac.uk agandesha@cru.rcpsych.ac.uk

Renata Souza Project Worker 020 7977 4977

rsouza@cru.rcpsych.ac.uk

Royal College of Psychiatrists’ Centre for Quality Improvement 4th Floor Standon House ● 21 Mansell Street ● London E1 8AA

www.nationalauditofdementia.org.uk

nad@cru.rcpsych.ac.uk