Hospitals have made important changes to improve dementia care, but staff say more support is needed.
Hospitals in England and Wales have made many positive changes aimed at making hospitals more “dementia-friendly”, an audit shows. Overall nearly 70% of carers rated care as excellent or very good, and 75% said that the person with dementia was definitely treated with respect by staff. Many more hospitals are providing dementia awareness training to all groups of staff, and 96% have a training framework for dementia care, up from 23% in the first round of audit in 2011. Nearly all hospitals (94%), have created dementia “champions” to lead change and support staff, following a recommendation made in Round 2. Staff however said they could not always access specialist support, especially out of hours.
Nineteen percent of staff surveyed said that patients with dementia had nutritional needs met only some of the time, and five percent said their needs were not met. Three quarters of staff (73%) said they could obtain food 24/7 for their patients. Food outside of regular mealtimes is necessary for people with dementia as many patients forget to eat or only eat little and often, because dementia has disrupted their sense of routine.
The National Audit of Dementia, commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), reviewed case notes of 10,047 patients with a diagnosis or current history of dementia and questionnaires from 14,416 staff and 4664 carers from 199 hospitals across England and Wales. The audit is managed by the Royal College of Psychiatrists in partnership with organisations representing healthcare professionals, people with dementia and carers.
The audit also found:
· Personal information on care and communication needs of people with dementia could not always be accessed by staff, and over half of carers thought staff could be better informed. A spot check carried out on selected wards found that half of the patients did not have the sheet with this information available, although almost all hospitals have systems to collect it.
· People with dementia were not always consulted about life changes, as one third (34%) of case notes recording conversations with social workers about potential transfers from family home to care home showed no record of consent to begin this process from patients (or proxies where patients did not have capacity to consent).
· Less than half of patients had a recorded initial assessment for delirium – a state of disorientation and confusion that can make dementia more rapid and even be fatal. People with dementia have a fivefold risk of developing delirium. Forty-five percent of patients were screened for the condition, compared to 38% in the 2013 audit.
Professor Mike Crawford, Director of the Centre for Quality Improvement at the Royal College of Psychiatrists said: “There are some encouraging improvements at a national level but achievement in improving care can vary between hospitals. For example, previous audits have recommended recording basic personal facts about a patient to aid care, but we are still not seeing this being consistently implemented.
“Something as simple as filling in a form with personal facts about a patient’s care cannot be overlooked when we know that dementia affects memory and can lead to severe communication difficulties.”
Key recommendations in the report are:
1. 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.
2. National Commissioners should propose a national programme aimed at embedding the collection, sharing and use of person centred information with a clear expectation this information will follow the patient between providers.
3. Chief Executive Officers and commissioning services should make sure when tendering for new catering contracts that access to finger foods and snacks 24 hours a day is included.
4. The Safeguarding Lead should ensure 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.
5. The Medical Director should ensure that hospitals have robust mechanisms in place for assessing delirium including appropriate assessment on admission and discharge with full recording of results.
Dr Oliver J Corrado, Consultant Physician to the Audit, Consultant Geriatrician and ‘Dementia Champion’, Leeds Teaching Hospitals NHS Trust said: “It is gratifying that the National Audit of Dementia has shown that hospitals and Trusts have continued to make significant improvements in the care of people with dementia. In particular, almost all now have a designated Lead Clinician to champion the care of people with dementia and have established regular groups and meetings to improve the care of this potentially vulnerable group of people. Many have also signed up to ‘John’s Campaign’ to further improve patient care and support carers.
However the audit has shown that there are some areas which could improve further. It is important that any person with dementia admitted acutely to hospital has their cognition (level of confusion) assessed routinely and that the possibility of delirium is excluded. Staff education and training in dementia has improved but could be even better and should encompass delirium as well and it is vital that patients’ nutritional needs are met. But a lot of progress has been made, it is very reassuring that 70% of carers felt standards of care were at least ‘very good’ and that patients were treated with respect by staff. I very much hope that this report will stimulate and encourage health service providers and commissioners to strive for even higher standards of care for people with dementia in future.”
Beth Swanson Lead Nurse Dementia, South Tees Hospitals NHS Foundation Trust and Consultant Nurse to the Audit said: “Over the past three rounds of the National Audit of Dementia we have seen significant improvements made by hospitals to improve care and experience for people with dementia. There is clearly more still to do. One key finding is that hospitals are developing good policies and guidelines for people with dementia but that these policies don’t always get fully put in practice. We can see that in feedback from carers and from staff. On the whole, there are notable markers of progress which should be celebrated. With continued investment and leadership across the NHS, care and experience for people with dementia will continue to improve”.