Dementia Assessment and Improvement Framework

Dementia assessment and improvement framework October 2017

1 The eight framework standards

Dementia Standard description Source Evidence Met Not met assessment and (state % improvement to standard achieve) Diagnosis There is an evidenced- Living well with dementia: A Evidence of a comprehensive based dementia care national dementia strategy (DH dementia assessment protocol pathway which 2009) (dementia strategy) includes a delirium Evidence of a comprehensive Delirium: prevention, diagnosis assessment where delirium assessment where and management (NICE 2010) clinically indicated clinically indicated The national dementia CQUIN Assessments are clearly (DH 2012) documented in the patient notes Prime minister’s challenge on The treatment of delirium follows dementia 2020 (DH 2015) evidence-based practice Assessment outcomes and Dementia: supporting people with treatment are recorded in the dementia and their carers in electronic discharge summary health and social care (NICE and Speak to staff; can they articulate Social Care Institute for the assessment criteria and Excellence (2006; updated 2016) forward actions required? Is there National audit of dementia (Royal a clear process ± SOP? College of Psychiatrists 2017) Patient and carer voice – “there’s a reluctance to diagnose dementia”

2 Person-centred There is evidence that Dementia-friendly hospital Patients say they are involved care the person and their charter (DAA 2012) Families/carers say they are carers have been Dementia: Commitment to the involved and listened to involved in care care of people with dementia in Observation – staff are seen to planning hospital settings (RCN 2013) involve patients and families/carers Patient voice – “involve me, listen Staff can describe how they to me” involve patients and CQC recommendation families/carers

Clinical team completes Dementia-friendly hospital Patients say they are involved the This is me booklet charter (DAA 2012) Families/carers say they are and involves patient and This is me (Alzheimer’s Society involved and listened to carer in this (if not 2016) Observation – staff are seen to already done in primary CQC recommendation involve patients and care) families/carers There is evidence of how Staff can describe how they this informs care involve patients and delivery families/carers, and how this There is evidence of how informs care delivery this is communicated and Patient record review shared across the multi- Ward leaders monitor the use of professional team the This is me booklet and can There are processes to articulate how to reduce variance ensure This is me is where it exists stored and used for Staff can describe the process for subsequent admissions/ storing and accessing This is me attendances at subsequent Personalised care is admissions/attendances delivered according to care plan meeting the patient’s needs Patient’s wishes relating to personal Person-centred care are respected.

3 care (contd) Evidence of discussion with relatives/ carers may be required Key at a glance Forget me not (Alzheimer’s Observation information is Society 2014) Patients say they are addressed by displayed above the The Butterfly Scheme (2013) their preferred name bed (with person’s or CQC recommendation Staff can describe how this carer’s agreement): supports the whole team in preferred name, likes, meeting patients’ needs dislikes and enhanced care needs (without breaching confidentiality)

Evidence that the Dementia-friendly hospital Patient record review principles of the charter (DAA 2012) Mandatory training compliance Mental Capacity Act Making a difference in dementia meets trust standards (2005) are followed (DH 2016) Observational evidence that staff relating to: seek people’s consent before providing care  consent  capacity assessment  best interest meeting Evidence that the Mental Health Act (DH 2007) Patient record review principles of the Mental Health Act code of Mandatory training compliance Mental Health Act practice (DH 2015) meets trust standards (2007) are followed Staff can articulate their relating to: understanding and application of the Mental Health Act and the Person-centred  protection of code of practice care (contd) patients’ rights under the act  staff compliance

4 with the code of practice People requiring Mental Capacity Act (2005) Patient record review deprivation of liberty Dementia-friendly hospital Staff can articulate their safeguards (DoLS) are charter (DAA 2012) understanding and DoLS identified and applications appropriate documentation is in place Staff can articulate Hospital policy Staff can describe safe-guarding safeguarding The fundamental standards process and their actions processes and their (CQC 2017) Patient record review responsibility in raising concern Incident report data Mandatory training compliance meets trust standards An appropriate pain Dementia-friendly hospital Patient record assessment tool is charter (DAA 2012) advises Staff can describe how and when used, for example the which pain assessment tools to to use Abbey Pain Score Abbey Pain Score or use with people with advanced Where appropriate, ask patients if the Pain Assessment dementia their pain is well controlled in Advanced Dementia Scale (PAINAD) A patient’s relatives and carers determine if the person’s pain is well controlled 50% of acute National audit of dementia (Royal Patient record review admissions relate to College of Psychiatrists 2017) falls, fractured hip, Falls in older people: assessing respiratory or urinary risk and prevention (NICE 2013) Person-centred infection care (contd) Evidence of multifactorial assessment and intervention with support from specialist

5 dementia and delirium teams where they exist Patients and carers CQC recommendation Patients and carers say they have are supplied with ward access to the information they information in suitable need formats Patients and carers know the Patients and carers name of the clinician they can know the name of the speak to responsible clinician and ward/service staff Patients and carers say they feel supported and informed about their care Information is shared National audit of dementia (Royal Review the discharge summary with relevant carers on College of Psychiatrists 2017) Feedback from GPs/care discharge homes/care agencies/families/ carers Complaints Incident notifications relating to discharge processes Evidence of a person- CQC recommendation Observe and listen to interactions centred culture – between staff members labelling and depersonalised Observe and listen to interactions language is not used between staff and patients Staff use care delivery Patients and carers say they are as an opportunity to treated with respect and dignity engage positively with people to increase their wellbeing Evidence of innovative Characteristic of trusts rated Patients and carers give examples ways to meet the ‘outstanding’ of how their needs have been met

6 person’s individual Staff say how they go the ‘extra needs; eg hair and nail mile’ to meet people’s individual treatments (where needs clinically appropriate). Patients and carers state “it’s the little things which count” Patient and Patients and Patient voice – Patents and carers say they families/carers feel received the help and support they carer “the support is not always information supported at the point wanted when diagnosed of diagnosis there when you are diagnosed, and support there are so many questions” “we need specially trained staff to be with us following the diagnosis” Use of different Dementia-friendly hospital Patients and carers say they have information and charter (DAA 2012) access to the type of information formats including The triangle of care (RCN 2016) they need in the best format for video and audio them Observation – information is available in different formats Information should be Accessible information standard Speak to patients and carers available in the (NHS England 2016) Information is available to the different languages public on wards that meet the needs of Ask “what’s missing?” the local community State the languages leaflets are available in Patient and carer Dementia café – jointly The triangle of care (RCN 2016) Patients and carers say they feel information hosted by the supported and have access to the Alzheimer’s Society information they need

7 and support and the clinical nurse (contd) specialist to provide support and education to people living with dementia and their carers Cafés may not work in every organisation. Other mechanisms should be reflected here Forums exist to Prevalent in trusts achieving Observation – attend a forum provide support and an ‘outstanding’ rating Patients and carers say they feel expertise to the carers supported and have access to the of people living with information they need dementia Review complaints/ compliments Staff say how they meet patient and carer needs Hospital staff who care Innovation adopted by some Staff in this position feel for a person living with trusts supported practically and dementia are offered emotionally support and advice People living with Dementia Connect Patient, family and carer feedback dementia and/or their (Alzheimer’s Society 2017) Written guidance is available carers are signposted to Dementia Connect Speak to the local Alzheimer’s Society regarding referrals from hospital-based services Staff can describe why and how they signpost to Dementia Patient and Connect carer People living with Dementia advisors: A cost Patients, families and carers say information dementia are effective approach to delivering they connect to local services and supported through the integrated dementia care receive/know how to access local

8 and support discharge process and (Alzheimer’s Society 2016) support services (contd) put in contact with Patient record review dementia advisors if not they are not known to the service Each organisation should provide details of the support services available locally. Dementia advisors may not be available in some areas The principles of John’s campaign (2014) Staff can describe principles and John’s campaign are how they apply them supported Dementia-friendly hospital Patients and carers are aware that Facilities are available charter (DAA 2012) families/carers can stay overnight for families/carers to if they wish stay overnight Align to trust approach – folding bed, reclining chair, washing facilities Family/carers have access to:  open visiting  drinks on the ward  concessionary parking (where parking exists)  concessionary food Patient and in hospital canteen carer Align to organisational policy where required

9 information Other innovative ways Innovation adopted by some Patients, carers and staff can and support of involving and trusts describe what these are and their (contd) supporting patients impact and families are implemented; eg ward- based tea parties Involvement Evidence of patient The triangle of care (RCN 2016) Patients, families and/or carers and co-design involvement in their Dementia-friendly hospital say if and how they feel involved care charter (DAA 2012) Staff say how they involve Making a difference in dementia families and carers Evidence of (DH 2016) Patient record review family/carer Patient voice – “speak to me not Observation of conversations involvement in my relative” patient’s care Patient voice relating to Staff are ‘carer aware’ involvement: and can articulate how “don’t involve me to tick a box, they engage with you need to listen” carers “I don’t want to be a token” Carers are identified at first contact or as soon as possible after this. Staff can articulate how they do this and how it influences care, and what the Involvement outcomes are for and co-design patients (contd) Patients, Dementia-friendly hospital families/carers are charter (DAA 2012) involved in discharge planning Care homes are Dementia-friendly hospital Speaking to care homes actively involved with charter (DAA 2012) (retrospective audit) discharge plans Patient record review

10 People living with A prevalent characteristic of Evidence in terms of reference dementia and carers trusts rated ‘outstanding’ and committee minutes sit on dementia Dementia 2020 citizens’ Speak to representatives strategy engagement programme (DH committee/other 2016) forums Patient voice: “if you want me People living with to be involved you need to Evidence of quality/service dementia and carers send me the briefing papers in improvement involving patients are involved in service advance” and carers; evidence in terms of redesign and dementia reference and meeting minutes pathway design and Speak to representatives evolution Workforce The workforce has Dementia-friendly hospital The trust’s education programme education and right knowledge and charter (DAA 2012) includes training in dementia and training skills to meet the Dementia core skills, education delirium needs of people living and training framework (Skills Trust’s education programme with dementia for Health/Skills for Care, HEE meets tiers 1, 2 and 3 training The workforce has 2015) recommendations right knowledge and Making a difference in dementia The agreed organisational skills in delirium and its (DH 2016) education and training rates are relationship to achieved (dataset to support National audit of dementia (Royal dementia, achievement) manifestations of pain College of Psychiatrists 2017) and behavioural and Staff say they are trained and psychological equipped with the right symptoms of dementia knowledge and skills to care for people living with dementia and Workforce delirium on an acute ward education and Evidence of how staff skills and training (contd) competency are assessed on an ongoing basis, eg observational tools or audits Staff have access to specialist advice if and when they need it

11 Patients and carers say that staff have the right knowledge and skills to care for person Staff have the right National audit of dementia (Royal Staff training records knowledge and skills College of Psychiatrists 2017) Staff say they have the right in: knowledge and skills following training  safeguarding Patients and carers say they feel  the Mental informed, involved and supported Capacity and Decisions are documented in the Mental Health Act, patient record including consent Appropriate use of best interests decision-making Training and education addresses the administration of covert medication as per organisational policy Use of lasting power of attorney and advanced decision-making DoLS Workforce education and Supportive training (contd) communication with family members and carers Dementia strategy Dementia-friendly hospital Staff can articulate how they states all non-clinical charter (DAA 2012) support and meet the needs of staff are trained in Dementia Friends (Alzheimer’s people living with dementia in all care of people living Society 2017) areas of the organisation

12 with dementia, eg Training records porters, reception Number of dementia friends staff, facilities and estates, and those working in hospital/ trust shops, cafés, restaurants, volunteers Dementia Friends promoted as part of strategy; organisation can give number trained as dementia friends Dementia Friends sessions do not replace training. They support a dementia friendly service at all levels Wider community is Feature of trusts rated Dementia strategy offered dementia ‘outstanding’ training, eg care home staff, other public service providers Leadership An organisational Dementia-friendly hospital Staff know of the dementia dementia strategy is charter (DAA 2012) strategy and can state its overall available, in date and aim meets national Staff know their part in meeting policy/best practice the strategy aims guidance Patients and carers say there is an organisational approach to meeting needs Evidence of dementia Feature of trust rated Dementia strategy and committee Leadership pathway development, ‘outstanding’ meeting minutes

13 (contd) working with GPs, Staff say what they are doing to CCGs, local authority, improve the dementia pathways social services, locally voluntary and third Patients and carers can describe sector to deliver a how the pathways are improving strategy to meet local needs Evidence of local Characteristic of trusts rated Staff can describe how they are application of the ‘outstanding’ by CQC contributing to improving care for dementia strategy. their patients who live with Staff can articulate the dementia improvements being made in line with the dementia strategy Evidence of clinical Characteristic of trusts rated Dementia strategy and the leadership: ‘outstanding’ by CQC minutes from meetings  organisational Dementia-friendly hospital Staff can say what they do and (consultant, charter (DAA 2012) how they make a difference consultant nurse or nurse specialist)  ward/department (dementia champions/link nurses with evidence of enhanced training and development) Dementia champions/link nurses need to provide evidence of how they are improving care Leadership standards (contd) Evidence of trust Characteristic of trusts rated Staff know which executive is the executive leadership ‘outstanding’ by CQC

14 dementia champion at board level A culture in which all staff acknowledge their part in meeting needs of people living with dementia irrespective of role they play in organisation The board sees data Feature of trusts rated Board reports for the numbers of ‘outstanding’ Speak to the dementia strategy patients moved at lead/director of nursing/medical night (between 23:00 director and 06:00 hours) for non-clinical reasons and plans to reduce them People trained in the National audit of dementia (Royal Speak to the staff to understand care of people living College of Psychiatrists 2017) their role and how it positively with dementia are impacts patients available 24 hours a Dementia strategy minutes day, seven days a week Environment Signage is appropriate Dementia-friendly hospital Peer inspection and assessment for people living with charter (DAA 2012) Consider Patient and carer dementia, including: Enhancing the healing applying this feedback/comment  words are environment (King’s Fund 2017) standard to all supported by Patient led assessments of the Staff feedback areas pictures care environment: dementia Business case – inclusion of  areas are colour friendly environments, guidance environmental planning for coded and for assessors (DH 2017) people living with dementia supported by Virtual hospital (Sterling themed pictures University 2017) Environment promotes meaningful interaction between patients, their families/carers and staff

15 Environment Where possible a seating (contd) area is provided with things to engage with, eg art and music The environment promotes wellbeing, including by:  using lighting that supports rest and sleep  allowing photographs and personal items to be kept near to the patient  encouraging eating and drinking, eg with areas where patients and families can eat together Flooring meets recommendations for people living with dementia Ward is clutter free People can see a working clock (shows time, day and date to orientate to time and place) There is a therapeutic environment which provides meaningful Environment activity; eg:

16 (contd)  reminiscence activity

 music – including local groups visiting the ward/Singing for the Brain (Alzheimer’s Society)

 Pets as Therapy visit patients in hospital People living with dementia and their carers/relatives are encouraged to bring their pet to hospital to visit the patient Pets as Therapy dogs visit wards so that patients can stroke a dog as a calming and therapeutic intervention PLACE audit meets the Improvement plans are in place required standard where required to respond to the PLACE audit with leads and timeframes Nutrition and All healthcare Nutrition support for adults: oral Training rates hydration professionals directly nutrition support, enteral tube Speak to staff to find out if they involved in patient care feeding and parenteral nutrition have the right knowledge and should receive education Clinical guideline 32 (NICE skills to meet needs and training relevant to 2017) Ask patients and carers if staff their posts support and enable people to meet their nutritional needs

17 Weight of all inpatients Policy review is assessed on admission. Notes review Include pre-assessment Staff can describe the process for for elective admissions this and its importance All inpatients are Policy review assessed using the Notes review malnutrition universal Minutes of relevant meetings; eg, screening tool (MUST) a nutrition and hydration Trusts to amend this committee (amend to align with standard if they use a existing organisational different nutritional structures) assessment Expert advice is Nutritional steering group minutes available from the Staff can say how they access multidisciplinary expert advice nutritional team; eg, Patients and carers have specialist nurse, dietician confidence patients’ nutritional and speech and language needs are met therapist Patient record review Care plans meet people’s Carer voice – six out of 10 carers Patients and carers say patients’ hydration and nutritional are concerned about the nutritional and hydration needs needs nutritional intake of a person are met Evidence of discussion living with dementia (Dementia- Staff can describe when and how with family or carer friendly hospital charter DAA they provide assistance 2012) The senior sister/charge nurses Nutrition and can describe the ways in which hydration (contd) people are helped at mealtimes or when they indicate they want food or a drink’ Patient record review Observation at mealtimes and when people ask for food or a drink

18 Patients with dysphagia Nutrition support for adults: Nutrition and hydration pathway are referred to a Clinical guideline 32 (NICE Staff know the causes of healthcare professional 2017) dysphagia and can recognise signs with the skills to manage and symptoms swallowing disorders Staff identify poor oral hygiene as a factor to consider before changing nutritional support Oral hygiene Patients and carers say patients get help with oral hygiene if they need it Staff can describe how they assess oral hygiene and the actions they take

Any clinical need is documented in the patient’s care plan Toothbrushes and toothpaste are available for patients who do not have these on admission Oral care kits are available and used where clinically appropriate Nutrition and Staff can describe the process for hydration (contd) keeping dentures safe to avoid loss A variety of foods are National audit of dementia (Royal Menu review available 24 hours a day, College of Psychiatrists 2017) Mealtime observation/audit including:  finger food  snacks/biscuits

19  food that can be provided outside the routine mealtimes Menus are routinely available in picture and large print format, and other formats if appropriate Appropriate crockery A well-led team which places and cutlery is available emphasis on meeting patients’ for people requiring hydration and nutritional needs is support, including: what makes the difference to patients; these are merely  coloured plates adjuncts to support delivery  adapted cutlery Patients and carers say patients’  coloured trays nutritional and hydration needs are met  water jugs with different coloured Staff can describe how they assist patients lids The senior sister/charge nurses Nutrition and can describe how the team works hydration (contd) to assist people at mealtimes or when people want food and drink Patient record review Observation at mealtimes and when people ask for food or a drink Carers are not asked to National audit of dementia (Royal Observation leave at mealtimes/ College of Psychiatrists 2017) Patients and families/carers say stopped from helping family members/carers are patients with meals encouraged to stay if they wish Carers and family National audit of dementia (Royal Observation

20 members are supported College of Psychiatrists 2017) Patients and families/carers say to be as involved as they family members/carers can be as want to be in meeting involved as they want to be patients’ nutritional needs

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