BOARD MEETING 25 JUNE 2014 AGENDA ITEM 3.6 DEMENTIA CARE ANNUAL REPORT 13/14 Report of Paper prepared by Purpose of Paper Action/Decision required Link to Doing Well, Doing Better: Standards for Health Services in Wales : Link to Health Board s Corporate Plan Acronyms and abbreviations Director of Nursing Dementia Lead To provide the Board with an update in relation to progress in implementing the Joint Dementia Plan for Powys To discuss and note the steps taken and the further actions to continuously improve the care of people with dementia and their families This paper supports Standards: 1. Governance and accountability framework 2. Equality, diversity and human rights 3. Health Promotion, Protection and Improvement 5. Citizen Engagement and Feedback 6. Participating in Quality Improvement Activities 7. Safe and Clinically Effective Care 8. Care Planning and Provision 9. Patient Information and Consent 10. Dignity and respect 11. Safeguarding Children and Safeguarding Vulnerable Adults 12. Environment 18. Communicating Effectively Improving Health & Well-Being Ensuring the Right Access Striving for Excellence Involving the People of Powys Making Every Pound Count Dementia Care Annual Report 13.14 Page 1 of 11 Board Meeting
DEMENTIA CARE ANNUAL REPORT 13/14 Introduction The Board prioritised through the Annual Plan 13/14 the development of care for people with dementia in Powys. This commitment focused on the delivery of key actions in a Joint Dementia Plan enabling a clear partnership approach between the teaching Health Board, Powys County Council, the Third Sector and people and communities themselves. This report outlines the work that has taken place during the year and gives a forward look at the priorities for 14/15. The Hearts and Minds Strategy: Together for Mental Health in Powys was approved by the Board and by the County Council in December 2012. As an all age strategy it included the approach that the thb with partners would take in improving the care and service available to people with dementia. This plan however overlaps with the work of the Integrated Pathways for Older People Group and therefore there is close connection in the work that has developed and will be developed in the coming year. Background Dementia describes a set of symptoms including memory loss, mood changes, problems with communication and reasoning. Dementia is caused when the brain is damaged by diseases, such as Alzheimer s disease or a series of strokes. Alzheimer s disease is the most common cause of dementia but not all dementia is due to Alzheimer s. The specific symptoms that someone with dementia experiences will depend on the parts of the brain that are damaged and the disease that is causing the dementia. Each person is unique and will experience dementia in their own way. The different types of dementia tend to affect people differently, especially in the early stages. How others respond to the person, and how supportive or enabling the person s surroundings are, also greatly affect how well someone can live with dementia. There are 820,000 people in the UK and 44,598 in Wales with Dementia Dementia prevalence increases with age, roughly doubling every 5 years for people aged over 65 years. 1 in 14 over 65, 1 in 6 people over 80, and 1 in 3 people over the age of 95, has some form of dementia Powys context The current population estimate for Powys is 133,071. (ONS 2011 Mid year population estimate). The over 65 age group is set to increase dramatically by 80% between 2008 and 2033. Among the older age groups the proportion aged 75 and over (10.6%) is higher than Wales (8.6%). The highest proportions are found in the Llandrindod Wells area. The pattern is very similar in those aged 85 and over. An estimated 6.3% of the Powys population was aged 80+ in 2009 (Wales 5.1%) The percentage of residents aged 80+ in Powys is projected to rise to 13.8% in 2033 (compared with 9.4% in Wales) and hence in Powys the number aged between 75 and 84 years (living with dementia) is estimated to increase from 839 in 2011 to 2522 in 2030 (Director of Public Health report for Powys). National Strategy There are a number of national strategies/action plans/targets that direct and support the work in this area. These include: Dementia Care Annual Report 13.14 Page 2 of 11 Board Meeting
National Dementia Vision for Wales Dementia Supportive Communities (Feb 2011). This is a long term vision statement with 6 high level commitments to improve services, information, training, research, and awareness raising. National Dementia Action Plan 2010-2015 The Welsh Government published this in 2010, included 45 actions focused on 4 key areas: 1. Improved service provision through better joint working across health, social care, the third sector and other agencies, including: a. Older people CMHTs to be fully integrated across health & social care b. Improve quality of general hospital care c. Reduce inappropriate use of anti-psychotics 2. Improved early diagnosis and timely interventions - originally timetabled for delivery in 2010-2011. 3. Improved access to better information and support for people with the illness and their carers. 4. Improved training for those delivering care and greater awareness of need for advocacy. This action plan includes requirements for improving dementia care research. The Dementia Care Intelligent Target As part of the 1000+ Lives Programme five targets or standards were selected as those having the most potential for driving high impact change at whole service system level to help advance delivery of some 45 of the actions in the National Dementia Action Plan. These include: 1. Memory Assessment/First point of contact reduce time between onset of symptoms & diagnosis being communicated 2. General Hospital Wards Identify diagnosis on admission, follow dementia care pathway, implement care planning/cpa bundle 3. Community care (including Residential care) - Appropriate use of anti-psychotic medications in accordance with NICE/SCIE guidelines, and avoidance where possible 4. Increase support to care givers involvement in care planning; educational bundle and therapeutic interventions. 5. NHS Dementia inpatient units admission bundle; interventions bundle; involvement of families/carers Powys Approach to Improving care and Wellbeing for people with Dementia and their families Powys thb has established with key agencies a Joint Dementia Plan, the delivery of which is overseen by the Joint dementia Steering Group. This group is chaired by the Director of Nursing and has active participation from the Local Authority, the Third Sector, frontline service provider (mental health) and general community hospital service providers. The Dementia Care Annual Report 13.14 Page 3 of 11 Board Meeting
Group reports through to the mental Health partnership which is driving forward the implementation of the overarching Hearts and Minds Strategy and also links to the Older Peoples strategy/integrated care Pathway for older people. The Powys Joint Action plan pulls together the themes from the Dementia Vision for Wales, Intelligent Targets for Dementia as well as the Dementia Action Plan for Wales. The action plan has four key themes. The key areas of progress against these 4 themes are also outlined briefly below: 1. Leadership and Accountability A Multi agency steering group has been established chaired by the Director of Nursing, with positive contributions from a wide spectrum of key stakeholders/partners in care. Terms of reference have been agreed and a time scaled action plan put in place and being implemented. A Dementia lead has been appointed to steer this work, however further review of the leadership resource in this are is required and will be undertaken in early 14/15. 2. Improving Care in Community Hospitals Much of the focus (National Audit for Dementia) across the UK and initiatives surrounding General Hospital care for people with dementia have been focused on District General Hospitals. Whilst this could be seen that Powys may miss out on the scrutiny this brings, there is also an opportunity in that cultures and working practices should be easier to change in small community hospitals. The learning therefore from General hospitals work is being adapted and adopted by community hospitals in Powys. On February 7 th 2014 the Chief Executive and Director of Nursing launched the Butterfly Scheme to all Community Hospitals in Powys. The Butterfly Scheme was created by Barbara Hodkinson following experiencing challenges with her mothers care in general hospital settings. The scheme has been adopted widely across the UK and has been recognised by the Department of Health. This is an opt-in scheme for people with dementia or cognitive problems where people are identified with a discreet Butterfly symbol next to their name. Staff are trained in a special response plan called REACH to better communicate with people with memory problems. Butterfly Scheme Champion volunteers are sought from each hospital department to ensure implementation and ongoing delivery of the scheme. In Powys, the Dementia Lead and Nursing Project Officer will be meeting with the Champions regularly to keep initial momentum going. 160 staff attended the first three day training programmes and feedback from staff has already been very positive. There is however much Dementia Care Annual Report 13.14 Page 4 of 11 Board Meeting
more work to do to enable all staff to be well prepared for caring for people with dementia and their families and this will therefore continue to be a major focus for the organisation during 14/15. Environment - It has been demonstrated that an appropriate environment can play a significant part in helping people with dementia with orientation and reducing agitation. The Kings Fund has developed research evidence based, dementia friendly audits for hospital environments. The ward based audit has been completed for all Community Hospital wards in Powys and the Dementia Lead and Project Officer are meeting with the Estates Department to develop and action plan to implement a range of recommendations. Refurbishments such as at Llanidloes hospital have enabled a dementia friendly approach to be adopted, however the changes required cannot wait for each hospital to be refurbished and therefore a more rapid approach to implementing key improvements will be progressed in partnership withy the estates and locality teams during 14/15. Dementia assessment tools and Delirium assessments are important to ensure that people with cognitive problems are identified on admission and placed on the appropriate care pathway. A small working group, led by a Consultant in Elderly Care have now completed final draft versions. It is intended that these should be rolled out throughout the Powys Community Hospitals to help coordinate and improve care. This is an essential action in order that people with early signs of dementia or delirium are identified and the appropriate care offered. This will improve the overall experience of care as well as outcomes, and is likely to prove more satisfying to staff in providing care for this group of people. 3. Caring well in Care Homes The NHS commissions care within the independent sector for people who have dementia. It is therefore essential that Care Homes are supported to deliver the best care experience and outcomes for residents. The medicines management team in Powys have made a significant impact by working with Care Homes to reduce anti-psychotic prescribing in people with mental health problems. They have managed to reduce prescribing from 29% to 21% in care homes. Essentially this means that more people are being supported without the use or with reduced use of medication to control symptoms. Importantly this work has been supplemented with producing checklist and advice for care homes and for carers. This has included: - Checklist for managing behavioural and psychological symptom associated with Dementia. - Antipsychotic Monitoring Form - Guidelines to Care Homes for addressing Challenging Behaviour Dementia Care Annual Report 13.14 Page 5 of 11 Board Meeting
- The Use of Antipsychotics in Dementia Information for Patients and their Carers This works needs to be integrated in to the work undertaken by older people s community mental health teams. They often in-reach in to care homes and carry out medication reviews as part of their work. The Dementia Lead is working on coordinating the efforts of the mental health and medicines management teams in order to enable a greater impact from the current resources. There are some good examples of specialist dementia care initiatives in care homes use by Powys residents but there is scope to share good practice and training. There is an opportunity for Health the Local Authority and Care Homes to work together to develop enhanced care settings and this will form part of the work into 14/15.. 4. Improving early assessment and care in the Community Good progress has been made in establishing memory assessment services across the county but the developments do tend to vary in the three mental health provider services with different levels of resources targeted to the service. A good service would include multidisciplinary input, pre assessment counselling, robust assessment processes and effective post diagnostic intervention. The overall aim should be to reduce the time of onset of symptoms to diagnosis but also include other improvement aims as contained in the Intelligent Targets for Dementia. It is essential that collectively services, including importantly those in primary care are able to identify people with early stages of dementia as this improves their quality of life and experience and enables a greater level of early support to be given to carers. Appendix 1 outlines the progress across Wales in improving diagnosis during the period 12/13. It indicates that Powys has been the most improved Health Board in relation to diagnosis during this period, however it also indicates that just under 40% of all people likely to have dementia in Powys have a diagnosis, leaving almost 1,500 people undiagnosed based on the Alzheimer s Society estimates. In Montgomeryshire the medical diagnostic sessions are completed in Out Patient Clinics. These sessions are supported by specialist nurse led review clinics. The nurse led clinics are held weekly, Thursday am in Welshpool and either Monday or Friday in Newtown. The Alzheimer s Society input in to the clinics to help with information and signposting. In Brecknock (with the exception of Ystradgynlais) and Radnorshire: There are a number of joint medical and nursing clinics and some nurse led sessions. Most of the clinics listed below also benefit from input from the Alzheimer s Society to help with information and signposting. [Crickhowell; once a month ; Wednesday am, nurse led. Wednesday pm, joint clinic (Consultant and Nurse). Bronllys, three times a month ; Wednesday pm joint clinic Builth Wells; two days a week; Monday nurse led; Friday am, joint clinic. Friday pm, nurse led. Brecon, every Monday am; nurse led review clinic. Knighton, twice a month; Thursday pm.] In addition to the above the Dementia Coordinator will carry out home visits to do pre screen, reviews and post diagnosis. Ystradgynlais- The Ystradgynlais team describe their service as more of a virtual clinic. The memory assessment nurse will undertake most of the initial assessments, often in the persons home, and refer those appropriate to the Consultant Psychiatrist in Out Patient Clinic, if a diagnosis is indicated. If a diagnosis of dementia is given then the nurse will follow up again and involve the Dementia Coordinator. The Dementia Coordinators contact details will be given to the patient and carer and will remain a source of contact throughout the person s journey with Dementia. Dementia Care Annual Report 13.14 Page 6 of 11 Board Meeting
Specialist services; Older people s community mental health teams are based in Welshpool, Newtown, Llandrindod, Brecon and Ystradgynlais. Specialist in-patient assessment services are available at Fan Gorau, Newtown Hospital. Clywedog Ward, Llandrindod Wells Hospital. Crug Ward, Brecon Hospital and Tawe Ward, Ystradgynlais Community Hospital. Following specific Welsh Government funding, each mental health provider areas has an identified Dementia Coordinator. Dementia Supportive Communities have gained an added impetus in Wales since the Dementia Champions training was introduced through the Alzheimer s Society in March 2014. The Health Board is supporting the development of the Brecon and Hay Dementia Supportive Community initiative. A small working group has been established with Health Board, Local Authority and PAVO membership to offer support to other communities as they express an interest in this initiative. There is significant potential for this work to grow in other places across Powys and this will be the focus of further work during 14/15. Priorities for 14/15 The main priorities identified build upon the work during 13/14 : 1. To improve the care of people with Dementia in community hospital settings (including outpatients and other non-ward departments) through the Butterfly Scheme and meeting the improvement areas in the Intelligent Targets. 2. Implementing a structured and tiered training programme across Powys (across agencies), including the potential for post registration modules of education provided in partnership between university of South wales and Powys teaching Health Board. 3. Improve support to Care Homes by building on current initiatives, supporting training, exploring the potential for a REACH type programme to be implemented and continuing the work in integrating the efforts of Medicines Management and Community Mental Health services. 4. Ensuring memory assessment services are available consistently across Powys and meeting targets on pre assessment, assessment and post diagnostic follow up. This includes the potential for undertaking an accreditation programme for each memory assessment services 5. Supporting (not leading) the development of Dementia Supportive Communities. 6. Focusing on care provision in older people s mental health wards, particularly in terms of standards of care and longer term sustainability. Report prepared by: Harold Proctor Assistant Nurse Director Presented By: Carol Shillabeer Director of Nursing Dementia Care Annual Report 13.14 Page 7 of 11 Board Meeting
Background Papers Financial Consequences Other Resource Implications Consultees A review of leadership resources, as well as implementation resource is being undertaken Dementia Care Annual Report 13.14 Page 8 of 11 Board Meeting
Appendix A Insert the 5 spreadsheets Ward OPD Day Hospital MIU Theatre Dementia Care Annual Report 13.14 Page 9 of 11 Board Meeting
Appendix B User Experience Fundamentals of Care Annual Audit (User Experience) Q99. Throughout your stay/attendance, how often did you feel that you and those that care for you, were given full information about your care in a way that you could understand? Q100. Throughout your stay/attendance, how often did you feel that you were treated with dignity and respect? Q101. Throughout your stay/attendance, how often did you feel that you were given the privacy that you need? Q102. Throughout your stay/attendance, how often did you feel that you were given help to be as independent as you can and wish to be? Q103. Throughout your stay/attendance, how often did you feel that the clinical area was kept clean, tidy and not cluttered? Q104. Throughout your stay/attendance, how often did you feel that when you called us that we responded in a timely manner? Q105. Throughout your stay, how often did you feel that you were provided with nutritious food and snacks? Q106. Throughout your stay/attendance, how often did you feel that you were provided with fresh drinking water and plenty of drinks when you need them? Q107. Throughout your stay, how often did you feel that you were given help with feeding and drinking if you needed this? Q108. Throughout your stay/attendance, how often did you feel that you were made to feel safe? Q109. Throughout your stay, how often did you feel that you were able to get enough rest and sleep? Q110. Throughout your stay, how often did you feel that you were made to feel comfortable? Q111. Throughout your stay/attendance, how often did you feel that you were, as far as possible, kept free from pain? Q112. Throughout your stay, how often did you feel that your personal hygiene needs were met? Q113. Throughout your stay/attendance, how often did you feel that if you needed help to use the toilet, that we responded quickly and discreetly? Q115. Throughout your stay/attendance, how often did you feel that you were given help to look after your skin to prevent you from getting pressure sores? Always Usually Sometimes Never Total Responses 82.41% 16.08% 1.51% 0.00% 199 93.53% 6.47% 0.00% 0.00% 201 91.46% 7.54% 1.01% 0.00% 199 87.23% 12.23% 0.53% 0.00% 188 90.00% 9.00% 1.00% 0.00% 200 79.55% 19.32% 1.14% 0.00% 176 78.08% 20.55% 1.37% 0.00% 73 87.60% 9.92% 1.65% 0.83% 121 85.71% 12.24% 0.00% 2.04% 49 93.09% 5.85% 0.53% 0.53% 188 74.42% 25.58% 0.00% 0.00% 86 87.37% 12.63% 0.00% 0.00% 95 83.05% 16.10% 0.85% 0.00% 118 92.73% 7.27% 0.00% 0.00% 110 82.05% 14.53% 1.71% 1.71% 117 84.62% 13.46% 0.96% 0.96% 104 Total 86.25% 12.61% 0.83% 0.31% 2291 Dementia Care Annual Report 13.14 Page 10 of 11 Board Meeting
Appendix C Staff Experience The Staff Questionnaire was only undertaken with Nursing and Health Care Support Worker staff within the audit areas. Where 20% of staff have expressed this never or only sometimes happens has been marked with a red dot. Fundamentals of Care Annual Audit (Staff Survey) Always Usually Sometimes Never Total Sometime s / Never Over 20% Total Responses Q85. Our organisation aims to, make sure you are able to access up to date information in order to be able to do your job. For example, access to policies, clinical guidelines etc. Do we achieve this? 62% 28% 10% 0% 10% 145 Q86. Our organisation aims to, ensure that as an employee you are treated with dignity and respect. Do we achieve this? 47% 36% 17% 0% 17% 146 Q87. Our organisation aims to, make you feel safe at work. Do we achieve this? 49% 39% 12% 1% 12% 146 Q88. Our organisation aims to, make you feel you have a positive contribution to patient care. Do we achieve this? 49% 37% 13% 1% 14% 143 Q89. Our organisation aims to, provide you with sufficient equipment to do your job. Do we achieve this? 32% 53% 14% 1% 15% 146 Q90. Our organisation aims to, provide you with opportunities to enhance your skills and professional development. Do we achieve this? 35% 40% 24% 1% 25% 144 Q91. Our organisation aims to, provide you with feedback on the outcomes of any incidents/accidents that you report or that are reported within your clinical area? Do we achieve this? 26% 38% 26% 10% 36% 142 Q92. Our organisation aims to, provide you with opportunity to identify and learn from good practice to bring about improvements in care. Do we achieve this? 38% 45% 14% 3% 18% 146 Q93. Our organisation aims to, provide opportunities for you to raise any concerns that you have. Do we achieve this? 48% 32% 16% 3% 20% 146 Q94. Our organisation aims to, provide you with the opportunity to establish a work life balance. Do we achieve this? 36% 43% 17% 3% 21% 145 Q95. Our organisation aims to, make you feel a valued member of the organisation and have a sense of belonging. Do we achieve this? 33% 32% 31% 3% 35% 144 Q96. Our organisation aims to, make you feel proud to be a nurse. Do we achieve this? 41% 36% 21% 3% 24% 140 Q97. Our organisation aims to, ensure that you have the knowledge and skills to deliver a consistent standard in the fundamental aspects of compassionate care. Do we achieve this? 50% 42% 8% 0% 8% 144 Total 42% 0 17% 2% 19% 1877 Dementia Care Annual Report 13.14 Page 11 of 11 Board Meeting