This example describes the use of NICE Quality Standard QS50 to guide training for staff in homes and act as framework for the ongoing provision of care. The example also describes the application of psychological based approaches resulting in reduced use of medication and admissions to hospital for residents and improved knowledge of the staff group. Consultation with older people, other agencies and charities to guide a dementia action plan, and a roundtable event with care home staff about their priorities leading to a harm free training programme, including living with dementia alongside other topics such as skin care and end of life care are also described.
The project has seen the re-design of services across all care sectors, pilot projects to guide work before rolling out to all areas resulting in improved rates of diagnosis of dementia, going from third worst national rates to better than average rates in two years and creation of services to help both patients and carers following an early diagnosis.
Aims and objectives
- To improve the care for people with dementia and their carers in Windsor and Maidenhead CCG (WAMCCG).
- Redesign of services to deliver care in line with NICE guidelines and good practice.
- A dementia strategy agreed by WAMCCG, Royal Borough of Windsor and Maidenhead Council (RBWM), Berkshire Health NHS Foundation Trust (BHFT), and all other agencies, charities and carer/patient organisations to guide the improvement of care. Public and staff consultation about their requirements for a better service.
- Improved recognition of dementia in all settings, and appropriate services and support once dementia is recognised.
- Improved care in care homes, increased knowledge of staff of psychological based approaches, reduced use of anti-psychotics, decrease in hospital admissions and use of NICE quality standards to guide the aims of care.
Reasons for implementing your project
Windsor and Maidenhead (WAM) did have traditional services of 3 day hospitals and little community development which resulted in little access to services for older people with dementia, and a disincentive for primary care services to identify dementia, and resulted in a dementia identification rate of 34% at the start of 2013, the third worst nationally and in an area of high numbers of older people and dementia. The closure of the day hospitals and reinvestment in community based services led to the establishment of memory clinics, home treatment teams, cognitive stimulation therapy (cst) groups, and carer education groups. The CCG obtained a Cameron Dementia Initiative Grant to introduce a well-being campaign via health activists with the population of older people and dementia screening with GPs.
By mid-2015 the identification rate was 63%, above the Thames Valley average rate of 58%. This work led to us becoming finalists for a HSJ award in 2014. A separate Cameron funded programme aimed at reducing the use of anti-psychotics in care homes by reviewing all individuals on such medication and was linked to a pilot in three care homes of staff training in the use of psychological based approaches. The pilot led to reductions in the use of anti-psychotics, increase in staff knowledge and reduced admissions to hospital. This was presented at the national FPOP and RCGP conferences in 2014, and is being rolled out to all 48 care homes in WAM this year as part of a “Harm Free” programme.
An innovation grant of £15,000 awarded for the establishment of CBT for carers groups to support stressed and depressed carers. This is a joint project between the CCG, BHFT (who provide the staff for the group), Alzheimer’s Dementia Support (a local charity who provide a sitting service to enable the carers to attend) and people to places (who provide transport) and which is run in community settings close to where people live. Two groups were run in 2014 and a third group for 12 carers in 2015,), the groups run for 12 weeks and have achieved good outcomes in terms of a reduction in stress and symptoms and improved wellbeing. With 47 care homes and an older than national average population, the number of people providing services and working in this sector, combined with the elderly residents themselves, make up a substantial percentage of the WAM population.
How did you implement the project
Projects were established to work across this sector and the Care Home Project was established in 2014. A Governance Board was formed of cross-sector stakeholders, who meet monthly to discuss quantitative data, drawn from multiple data-bases, as well as qualitative information from ‘eyes and ears’ feedback.
Networking and Engagement
A networking and learning event was organised and attended by over 70 care home staff. The event provided the opportunity to participate in mini workshops, network and link up with clinical and third sector participants. Feedback highlighted accessible training and networking opportunities were key priorities.
Improving Care Home Environment Initiative
This was pump-primed by the winning of a £870,000 fund to improve dementia services in 17 care homes. These projects are now coming to completion with new state of art facilities. Many homes have seen such positive results for residents, families and staff, that additional investments are now being made.
In 2014, NICE issued Quality Standard 50 (QS50) for the mental well-being of elderly people in care homes. WAMCCG followed the NICE approach and held a roundtable event with relevant stakeholders including third sector and care homes managers. This collaboration resulted in a plan and process to operationalise the 6 NICE quality statements in the Standard across the 47 care homes.
The workshop content is based upon the stepped care model for assessment and intervention (BPS 2013), and Improving Dementia Care by Loveday & Kitwood (2000) the basis for Fossey’s (2013) work on reducing the use of anti-psychotics and has had good outcomes in terms of increasing staff knowledge, reduction in use of anti-psychotics and reduction in unelected admissions. This work has been shortlisted for a Patient Safety Award 2015.
Harm Free Care Campaign (HFCC)
The dementia plan is now part of the HFCC. As part of the national preventative strategy and in response to care home staff feedback, the HFCC was launched in January 2015. This is a joint collaboration between the RBWM and WAMCCG and is being funded in part by the HETV fund.
The HFCC address the major causes for NELs in WAMCCG as taken from the care home dashboard. In collaboration with Bracknell and Wokingham College and BHFT a HFC course comprising of the five key health challenges were developed, including Living with Dementia. The living with dementia component has been delivered to nine care homes and two teams supporting residents in sheltered housing so far in 2015 and is scheduled to be delivered across the other care homes.Its aims are to train staff in residential/nursing homes to use psychological approaches to be able to improve care in relation to the NICE Quality Standard (QS50) enabling residents to:
Participate in a meaningful activity
Maintain and develop their personal identity
Have signs and symptoms of mental health conditions recognised and recorded as part of their care plan
To have specific needs arising from sensory impairment recognised and recorded as part of their care plan
To have symptoms and signs of physical problems recognised and recorded as part of their care plan
To have access to the full range of healthcare services when they need them.
Key learning points
- In summary we have shifted the emphasis of our care for people with dementia to community settings, have identified more people earlier and offered them and their carers more support, have improved the environment of our care homes and are helping the staff in these settings to provide better care.
- The QS50 NICE Quality standards guided the training of staff in care homes and gave them a clear sense of the objectives of the care that they were providing.
- It was important that the care home project was part of an agreed dementia strategy which involved introducing change and improvements across all agencies/charities/organisations, better results were achieved by the accumulated impact of projects, i.e. changes to environment combined with a drive to reduce anti-psychotics and staff training, rather than anyone individual project alone.
- Staff consultation and public involvement is important as a strategy to improve dementia care requires support and input from all. We found that pilot projects were essential to overall success as they offered the opportunity to try out approaches and make changes prior to wider implementation.