Review of Dementia Services

Transcription

1 Review of Dementia Services Dudley Health Economy Visit Date: 20 th January 2012 Report Date: March 2012 Images courtesy of HS Photo Library and Sandwell & West Birmingham HS Trust WMQRS dudley dementia final report V doc 1

2 IDEX Introduction... 3 Key Points... 4 Health Economy... 5 Dementia Service(South Staffordshire and Shropshire Healthcare HS Foundation Trust)... 7 In-Patient Services (Dudley and Walsall Mental Health Partnership HS Trust)... 8 Commissioning... 9 Appendix 1 Membership of Visiting Team Appendix 2 Compliance with Quality Standards WMQRS dudley dementia final report V doc 2

3 ITRODUCTIO West Midlands Quality Review Service (WMQRS) was set up as a collaborative venture by HS organisations in the West Midlands to help improve the quality of health services by developing evidence-based Quality Standards, carrying out developmental and supportive quality reviews - often through peer review visits, producing comparative information on the quality of services and providing development and learning for all involved. Expected outcomes are better quality, safety and clinical outcomes, better service user and carer experience, organisations with better information about the quality of clinical services, and organisations with more confidence and competence in reviewing the quality of clinical services. More detail about the work of WMQRS is available on This report presents the findings of the review of dementia services which took place on 20 th January The visit reviewed compliance with, and identified related issues, for the following WMQRS Quality Standards: Dementia Services, Version 1, February 2011 These visits were organised by WMQRS on behalf of the West Midlands Dementia Care Pathway Group. The report gives external assurance of the care within the Health Economy which can be used as part of organisations Quality Accounts. For commissioners, the report gives assurance of the quality of services commissioned and identifies areas where developments may be needed. The report reflects the situation at the time of the visit. The text of this report identifies the main issues raised during the course of the visit. Appendix 1 lists the visiting ream which reviewed the services at Dudley health economy. Appendix 2 contains the details of compliance with each of the standards and the percentage of standards met. ACKOWLEDGEMETS West Midlands Quality Review Service would like to thank the service users and carers and staff of the Dudley health economy for their hard work in preparing for the review and for their kindness and helpfulness during the course of the visit. Thanks are also due to the visiting team and their employing organisations for the time and expertise they contributed to this review. WMQRS dudley dementia final report V doc 3

4 SERVICES FOR PEOPLE WITH DEMETIA I DUDLE KE POITS 1 A Dementia Service for Dudley had been running on a pilot basis since June This review found that good progress had been made with establishing an assessment service, in particular, good links with general practices had been developed. Reviewers were, however, seriously concerned about several aspects of the assessment and diagnosis process, including compliance with ICE guidance. 2 In-patient services for people with dementia provided by Dudley and Walsall Mental Health Partnership Trust were well organised with good information and support available for people with dementia and their families. 3 Reviewers were concerned about the lack of a finalised overall commissioning strategy for services for people with dementia. The roles of the Dementia Service, day hospitals, community mental health teams and in-patient services, and the pathway for service users after diagnosis were therefore not clear. Liaison and communication between the different providers of services was not yet well developed. 4 Good links with social care were evident and reviewers were impressed by the Dementia Gateways, including links with the Dementia Advisers. WMQRS dudley dementia final report V doc 4

5 HEALTH ECOOM Services for people with dementia were not reviewed in the main WMQRS visit to Dudley in May At that time services were being re-commissioned and the new service had not yet started. A follow-up visit to Dudley was therefore arranged for 20 th January This review did not cover long-term care or the contribution to social care of voluntary and private sector organisations, although reviewers met representatives of the Alzheimer s Society and Tele-health. Health services for people with dementia were provided by several providers. Service for People with Dementia Provided by otes Primary Care Dementia Gateways Three Dementia Gateways helped people with dementia and their carers to access a range of housing, social care, benefits advice, advocacy and other services. Dementia Service Two clinical nurse specialists and three dementia advisers were in post. These staff met weekly with staff providing services for people with dementia employed by Dudley and Walsall Mental Health Partnership HS Trust and the psychologist from the Black Country Partnership HS Foundation Trust. Community Mental Health Teams, Day Hospitals, In-Patient Care and Consultant Psychiatrists Dementia Service for Adults with Learning Disabilities General Practitioners Community Services (Dudley Group HS Foundation Trust) Dudley MBC South Staffordshire and Shropshire Healthcare HS Foundation Trust The clinical nurse specialists were employed by South Staffordshire and Shropshire Healthcare HS Foundation Trust. Dementia Advisers were employed by Dudley MBC. Dudley and Walsall Mental Health Partnership HS Trust Black Country Partnership HS Foundation Trust Plans to appoint a Primary Care Dementia Liaison Worker were being developed. These services were not reviewed in detail but the review was based in the Brett oung Gateway. This service was set up in June 2011 as a one year pilot and started work initially in the north of Dudley borough. CMHTs were reviewed in May 2011 and so are not covered by this report. This team provided support and care for people with learning disabilities and dementia and input to the multi-disciplinary discussion in Dudley. This review looked in detail at the Dudley Dementia Service and at in-patient care on Clee ward at Bushey Fields Hospital. CMHTs were reviewed as part of the May 2011 visit, the report of which is available on the WMQRS website: Referrals from GPs were sent to the Dementia Service, to the consultant psychiatrists or to CMHTs. Physical health screening and an initial memory assessment was undertaken by GPs. People referred to the Dementia Service then had an initial assessment in their own home by the clinical nurse specialist. The service was becoming more widely known and the number of referrals had recently increased. Following multi-disciplinary discussion, service users were either referred back to primary care, to social care or for other support, or were followed up by consultant psychiatrists or CMHT. People referred through the Dementia Service were offered a Dementia Adviser who worked with them to develop a person support plan. People with learning disabilities could self-refer or be referred to the Dementia Service for Adults with Learning Disabilities. WMQRS dudley dementia final report V doc 5

6 A weekly multi-disciplinary team meeting involved Dementia Advisers and staff from the Dementia Service, Dudley and Walsall Mental Health Partnership HS Trust and the Black Country Partnership HS Foundation Trust. There was a Dudley Dementia Strategy Group, a Local Implementation Team for dementia services and a monthly Monitoring Group for the Dementia Service. Dudley Group HS Foundation Trust was involved, particularly in the Monitoring Group, with the aim of improving care in the acute hospital and improving links with other services in the borough. Good Practice 1 The Dementia Gateways provided a good focus for the care of people with dementia. A wide range of information and services were available in a friendly, welcoming environment. A Dementia Adviser was based in each of the three Gateways. The Gateways also enabled communication and liaison between social services, the Dementia Service, Alzheimer s Society and other agencies, thereby supporting a holistic approach to meeting the needs of people with dementia. One Looking After Me programme had been run and there were plans to evaluate this and run further programmes. Concern 1 Clinical Governance: Multi-disciplinary meetings Weekly multi-disciplinary meetings were held involving Dementia Advisers (Dudley MBC), specialist nurses from the Dementia Service (South Staffordshire and Shropshire Healthcare HS Foundation Trust), consultant psychiatrists from the Dudley and Walsall Mental Health Partnership HS Trust and a clinical psychologist from the Black Country Partnership HS Foundation Trust. The consultants involved had not seen the patients who were being discussed and did not have clinical responsibility for the work of nursing staff from the Dementia Service. It was not clear which organisation was taking governance responsibility for the decisions of the multi-disciplinary meeting. Further Consideration 1 Provider Liaison and Communication Staff in some services for people with dementia were not aware of the roles of other services and reviewers were given several examples of operational and clinical issues which could have been resolved by better awareness and communication between services. As well as resolving clinical and operational problems, there may be opportunities for shared training, development and audit. Good liaison and communication between providers is particularly important for Dudley because of the number of different provider organisations involved in the care of people with dementia. Some of these providers met through the weekly multi-disciplinary meeting or were involved in the monthly Dementia Service monitoring meetings but both of these meetings had other primary functions. 2 People with dementia who were diagnosed before the summer of 2011 (2012 for some parts of the borough) had not had the information and support available since then from Dementia Advisers and Dementia Gateways. Further consideration of meeting the needs of this group may be helpful. Also, the role of Dementia Advisers was described as preparing a Personal Support Plan and then reviewing this plan with people with dementia and their carers. It may be useful to model whether three Dementia Advisers will be sufficient to carry out this role as the numbers of reviews builds up. 3 Consultant psychiatrist staffing may not be sufficient if ICE Guidance on the diagnosis and assessment of dementia is implemented for the whole of Dudley (see below). WMQRS dudley dementia final report V doc 6

7 DEMETIA SERVICE (SOUTH STAFFORDSHIRE AD SHROPSHIRE HEALTHCARE HS FOUDATIO TRUST) General Comments and Achievements The Dementia Service had been running since June 2011 and the second clinical nurse specialist (CS) had been in post since December The number of referrals to the service had started to increase since the service had been rolled out to the whole borough. (190 people had been referred since June 2011 and 40 of these had been in the three weeks preceding the review.) Dementia Advisers were based in each of the three Gateways and the two CSs were based in the Brett oung Gateway in Halesowen. The service had engaged well with local GPs and staff should be proud of the progress they had achieved in the time available. A good range of cognitive assessments were used. Good Practice 1 A good GP referral process had been developed with clear documentation and good communication with GPs about their responsibilities before referral. Immediate Risk: one Concerns 1 Diagnostic and assessment process Reviewers were seriously concerned about the diagnostic and assessment process for a combination of reasons: a. Governance This service was provided by South Staffordshire and Shropshire Healthcare HS Foundation Trust but clinical responsibility for patients at each stage of the diagnostic and assessment process was not clearly explained to reviewers and documentation provided was not consistent with verbal information given to reviewers. b. ICE Guidance ICE guidance on diagnosis of dementia was not being followed. The service did not provide a full range of assessment and diagnostic services as expected by ICE guidance. The service relied on GPs to have undertaken a physical examination and medication review. Some patients did not see a consultant or other appropriate senior doctor specialising in the care of dementia prior to diagnosis. For those people diagnosed with dementia by nursing staff, it was not clear diagnosis included appropriate consideration of medical co-morbidities, key psychiatric features associated with dementia, including anxiety and depression, and differential diagnosis. Structural imaging (CT or MRI) did not take place prior to diagnosis. Memory Clinics were not held. c. Competences of staff undertaking diagnosis and assessment ursing staff were diagnosing straight-forward cases of dementia (as required by the service specification). Although the person specification for the clinical nurse specialist posts required Clinical skills in the assessment and diagnosis of dementia, reviewers did not see evidence at the time of the review that nursing staff had the competences needed for the role they were taking in the diagnosis and assessment of people with dementia (see above), in particular, competences in physical examination, medication review and differential diagnosis. WMQRS dudley dementia final report V doc 7

8 d. Guidelines and Policies Further Consideration o operational policy or guidelines, including guidelines covering the assessment and diagnostic process, were evident at the time of the review. 1 Provider Liaison and Communication: See health economy section of this report I-PATIET SERVICES (DUDLE AD WALSALL METAL HEALTH PARTERSHIP HS TRUST) General Comments and Achievements At the time of the review, the in-patient ward for people with dementia had seven people in a ward with a capacity for 16. Most of the in-patients had challenging behaviour as well as dementia. Staffing was used flexibly with other wards in the hospital. There was a good sensory room. Links with consultant psychiatrists, day hospitals and CMHTs were good. The ward was not yet using the OASIS IT system but there were plans for this to be implemented. Good Practice 1 Information for service users and their carers was good including a person-centred care plan, a Welcome Pack, information on Understanding what your named nurse can do for you and a My Keeping Well pack. Concerns: one Further Consideration 1 Provider Liaison and Communication: See health economy section of this report 2 In-patients were not able easily to access their rooms during the day. 3 It was not clear that nursing staff had specific competences for their roles in caring for people with dementia, especially if staffing levels were increased in order to increase capacity on the ward. 4 It may be helpful to review the stage in the in-patient stay at which information is given to service users and carers. Reviewers were told that the Social Worker input focussed on discharge planning, which though important, other relevant information and advice e.g. benefits advice, may be helpful earlier in the inpatient stay. 5 There was little difference in the decor in different areas of the in-patient ward. The corridors were almost identical and although there had been some attempt to paint the door frames and put visual prompts to identify rooms the environment was still very similar. Improving the decoration with the aim of specifically addressing the needs of people with dementia may make the environment more conducive for service users and carers. WMQRS dudley dementia final report V doc 8

9 COMMISSIOIG General Comments and Achievements HS Dudley had started to improve the care of people with dementia through the development of the Dementia Service. Links with Dudley MBC on developing services for people with dementia were good. Concern 1 Dementia Strategy A draft strategy for was available but this did not reflect the services being provided or planned at the time of the review. Completion of the strategy was planned on conclusion of the Dementia Service pilot. Reviewers were seriously concerned about the fragmentation and unclear governance of the diagnosis and assessment pathway (see above). The pathway for people referred to the Dementia Service did not comply with ICE guidance and was not clear about responsibilities for follow up and ongoing support. The pathway for people referred to consultant psychiatrists or CMHTs was not clear. The roles of the day hospitals and CMHTs in the ongoing care of people with dementia were not clear. Links between these services and the Dementia Advisers and Dementia Gateways were not evident. Reviewers were told that the in-patient unit now admitted mainly people with challenging behaviour and dementia (see above). This may be appropriate but it was not clear that this was part of a strategic direction supported by commissioners. Further Consideration 1 Some staff were unclear whether the Local Implementation Team (LIT) included representatives from the Black Country Partnership HS Foundation Trust. It may be helpful to review attendance to ensure appropriate representation of the service providing care for people with learning disabilities and dementia. It may also be helpful to review whether both a LIT and a Strategy Group are required. WMQRS dudley dementia final report V doc 9

10 APPEDIX 1 MEMBERSHIP OF VISITIG TEAM Michael Bennett Lead Joint Commissioning & Contracting Manager HS Telford and Wrekin Jim Bulman Carer Worcestershire Cathy Knight Dr Pravin Prabhakaran Community Mental Health urse Older Adults Consultant Older Adult Psychiatrist Dr James Shipman Assistant Medical Director and GP HS Stoke Coventry and Warwickshire Partnership HS Trust Worcestershire Health and Care HS Trust Simon Wheeler CPA Lead Coventry and Warwickshire Partnership HS Trust WMQRS members: Jane Eminson Acting Director West Midlands Quality Review Service Sarah Broomhead Quality Manager West Midlands Quality Review Service WMQRS dudley dementia final report V doc 10

11 APPEDIX 2 COMPLIACE WITH QUALIT STADARDS Analyses of percentage compliance with the Quality Standards should be viewed with caution as they give the same weight to each of the Quality Standards. Also, the number of Quality Standards applicable to each service varied depending on the nature of the service provided. Percentage compliance takes no account of working towards a particular Quality Standard. Reviewers often comment that it is better to have a o but, where there is real commitment to achieving a particular standard, than a es but where a box has been ticked but the commitment to implementation is lacking. With these caveats, table 1 summarises the percentage compliance for each of the services reviewed. Table 1 - Percentage of Quality Standards met Dementia Services Service o. Applicable QS o. QS Met % met o. services / clinical areas Dudley Primary Care Memory Service (South Staffordshire & Shropshire Healthcare HS Foundation Trust) Dementia In-patient Ward (Dudley and Walsall Mental Health Partnership HS Trust) Commissioning: HS Dudley Health Economy Totals South Staffordshire & Shropshire Healthcare HS Foundation Trust Dudley and Walsall Mental Health Partnership HS Trust HS Dudley Health Economy WMQRS dudley dementia final report V doc 11

12 DEMETIA PRIMAR CARE HS Dudley Ref Quality Standard Met? Comments Support for Service Users and Carers KA-101 Awareness Information Information should be clearly displayed in waiting areas for people who are concerned about dementia, including the availability of cognitive self-assessment on HS Local and who to contact if they have concerns. KA-102 KA-103 KA-104 Advocacy Information Information on advocacy services available for patients should be clearly displayed. Referral Information Information should be offered to all patients referred to the Memory Assessment Service covering at least: a. Brief description of the Memory Assessment Service (for example, what the memory assessment will cover, what will happen during the assessment). b. Opportunity to talk to the Primary Care Dementia Liaison Worker (or equivalent) before attending c. Arrangements for memory assessment with a clear indication of timescales d. How to contact the Memory Service e. Availability of further information. Physical Health Review Each general practice should have offered a physical health review to all patients with dementia at least annually, and more frequently if needed. This review should include, at least: a. Keeping healthy and preventing disease b. Review of medication c. Details of main carer/s and, if appropriate, review of carer/s support needs The outcome of the health review should be summarised in writing to the service user and, if appropriate, their carer, and should be recorded in their notes. o evidence of practice audits was available. Some information from QOFF performance schedules was seen. Staffing KA-299 Training and Development General practice staff should participate in the programme of training and development of primary care staff in dementia prevention, recognition, screening, early intervention, user and carer experience, ongoing care, local services and how to obtain advice in an emergency (QS KZ-299). There were plans for this to start in June WMQRS dudley dementia final report V doc 12

13 HS Dudley Ref Quality Standard Met? Comments Guidelines and Protocols KA-501 Referral Guidelines Guidelines on seeking advice from and referral to the Memory Assessment Service should be easily available. These guidelines should cover, at least: a. Physical health review to identify potentially reversible physical health problems b. Use of a cognitive screen suitable for primary care c. Offering the opportunity to talk to the Primary Care Dementia Liaison Worker (or equivalent) d. Consent for referral. Good referral guidelines had been distributed. KA-502 KA-597 Dementia Care Guidelines Each general practice should have guidelines on the care of patients with dementia in use and their implementation should have been audited. These guidelines should cover, at least: a. Alternatives to prescribing b. Prescribing, including prescribing of antipsychotic medication c. Physical health review (QS KA-104) d. Indications and arrangements for seeking advice in an emergency (QS K-204). Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use. There was no evidence of compliance with this QS. Service Organisation and Liaison with Other Services KA-601 Primary Care Dementia Liaison Worker A lead professional should be available with responsibility for: a. Supporting people who are concerned about memory loss and their carers before referral to the Memory Service b. Liaison between general practices, memory services, voluntary organisations and long-term care providers c. Supporting the training and development of primary care and long-term providers staff in the identification and care of people with dementia d. Ensuring people with dementia who do not have a general practitioner (for example, travelling families or people who are homeless) have regular physical health reviews and access to dementia services. There should be cover arrangements for absences of the lead professional. Two clinical nurse specialists were in post but did not have all the responsibilities expected by the QS. There was also a GP Clinical Lead for Dementia. Some services also covered parts of these responsibilities, including Dementia Advisers and the Alzheimer Society. WMQRS dudley dementia final report V doc 13

14 HS Dudley Ref Quality Standard Met? Comments Governance KA-701 Practice Register Each general practice should have a register which identifies people with dementia registered with the practice, including: a. Demographic details b. Appropriate Read codes This information should be shared with commissioners as required for the purpose of needs assessment (QS KZ- 702) MEMOR SERVICES Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments Support for Service Users and their Carers K-101 K-102 General Support for Service Users and Carers Service users and their carers should have easy access to the following services. Information about these services should be easily available: a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. Relevant support groups h. HealthWatch or equivalent organisation i. Where to go for further information Memory Service Information Service users and, where appropriate, their carers should be offered information about the Memory Service covering, at least: a. Brief description of the service b. How to contact the service for help and advice, including out of hours c. Staff of the service d. How to give feedback on the service, including how to make a complaint and how to report adult safeguarding concerns e. How to get involved in improving services (QS K-199) f. Belongings, visiting times and daily routine (in-patient services only) The QS was met except for information on spiritual support, independent advocacy and interpreter services. A guide to dementia gateways was available but this did not include access to the Dementia Service. Information covering the requirements of the QS, including how to make a complaint, was not available. The Welcome to Bushey Fields' book was comprehensive. It was given patients prior to admission and was available in the day hospital WMQRS dudley dementia final report V doc 14

15 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments K-103 K-104 K-105 Memory Clinic Environment The memory clinic environment should be welcoming and suitable for people with memory problems and their carers. Key Worker Each service user and, where appropriate, their carer should be given the name of a key worker who they can contact for queries and advice. Care Plan Each service user and, where appropriate, their carer should agree their Care Plan. Service users and, where appropriate, their carers should be offered a copy of their Care Plan covering at least: a. Their memory assessment and any planned therapeutic interventions (including pharmacological and nonpharmacological interventions) or referrals b. Their social care assessment and any planned social care support or referrals c. Their assistive technology assessment and any planned assistive technology support or referrals d. Their Looking to the Future assessment and any agreed actions. e. Their carer s assessment (QS K-198) and any planned carer s support or referrals (if appropriate) f. ame of Dementia Pathway Coordinator or alternative key worker for queries or advice g. Emergency help line (QS K-204) h. Early warning signs of problems and what to do if these occur i. Risk management plan j. Planned review date and how to access a review more quickly, if necessary. Service users were visited in their own home for their first assessment. Memory clinics were not run. Three dementia advisers were in post and worked with service users for, initially, up to six months. Service users also had the contact details of the clinical nurse specialist. Reviewers did not see evidence of care plans. /A Information about the Dementia Pathway Coordinator was not always clear. WMQRS dudley dementia final report V doc 15

16 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments K-106 K-107 K-108 K-109 K-110 Information on Memory Assessment and Therapeutic Interventions Information should be offered to service users and, where appropriate, their carers covering, at least: a. Dementia, its causation and potential impact b. Investigations and therapeutic interventions c. Promoting good health, including diet, exercise and smoking cessation d. Where to go for further information, including useful websites Information on Social care Information should be offered to service users and, where appropriate, their carers covering, at least: a. Support services available b. Social services assessments of care needs and how to access an assessment c. Access to personal budgets for care d. Where to go for further information, including useful websites. Information on Assistive Technology Information should be offered to service users and, where appropriate, their carers covering, at least: a. Assistive technology available b. Where to go for further information, including useful websites. Information on Looking to the Future Information should be available for service users and, where appropriate, their carers covering, at least: a. Legal implications of dementia and how to access legal advice b. Benefits advice c. Driving advice and DVLA notification d. Implications for travel and insurance e. Advance care planning f. Genetic counselling g. End of life care. Information for Carers Information should be offered to carers covering at least: a. Support services available b. Carer education and training programmes available c. Who to contact in a crisis d. Where to go for further information, including useful websites A dementia 'gateways' leaflet was available but did not cover therapeutic interventions offered by the Dementia Service. Reviewers were told that additional information was given as required. Information was not easily accessible. Information was available from the social workers. It was not clear if information was readily available in the absence of the social worker. A good pack was available explaining about 'telecare' and how each specific piece of equipment could help. Reviewers did not see information about advance care planning, legal implications of dementia or genetic counselling although they were told that verbal information on these subjects was given as required. Some of the information was available from the social workers. It was not clear if information was readily available in the absence of the social worker, and the MDT assessment of need may not prompt the relevant discussion with service users. WMQRS dudley dementia final report V doc 16

17 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments K-198 K-199 Carer Assessment Each carer should be offered an assessment of their own needs and information and advice on services available to provide support. Involving Users and Carers The service should have: a. Mechanisms for receiving feedback from service users and carers b. A rolling programme of audit of service users and carers experience c. Mechanisms for involving service users and, where appropriate, their carers in decisions about the organisation of the service. Alzheimer Cafes and other support group were available. Mechanisms for feedback and involving users in the Dementia Service were not yet in place. It may be helpful to develop these as part of evaluation of the pilot. Carers groups were in place and regular patient satisfaction audits were undertaken. Staffing K-201 Lead Practitioner and Manager The Memory Service should have a nominated lead practitioner and lead manager. There was a nominated lead practitioner. A lead manager from the Local Authority met the reviewing team. Managerial responsibility for the Dementia Service was not clear at the time of the review and no lead manager from South Staffordshire and Shropshire Healthcare HS Foundation Trust was identified. WMQRS dudley dementia final report V doc 17

18 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments K-202 K-203 Staffing Levels The Memory Service should have sufficient staff with appropriate competences to deliver: a. The assessments and therapeutic interventions for the usual number of referrals and their usual level of need / complexity of care required. b. The service s role in follow up and ongoing support (QS KZ-601) Staffing levels should be based on a competence framework (QS K-203) covering skill mix, staffing levels and competences expected. Staff should have time allocated for their work with the Memory Service. In order to achieve the necessary competences, staffing should include a consultant psychiatrist or appropriate other senior doctor specialising in the care of people with dementia, mental health nurse, clinical psychologist or neuropsychologist, and occupational therapist. Competence Framework and Training Plan A competence framework should cover expected competences for roles within the service, including in Safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards. A training and development programme should ensure that all staff have, and are maintaining, these competences (QS K-202). The Dementia Service had two clinical nurse specialists who met Dementia Advisers, consultant psychiatrists and a psychologist at the weekly MDT meetings. Input from OT was available as required. See main report about the governance of the service and MDT meetings. urse staffing levels may not be sufficient as the number of referrals increases. Reviewers commented that two consultant psychiatrists may also not be sufficient for the population of Dudley with dementia. The person specification for the CS posts identified the competences expected and both nurses were provided with clinical supervision and mentorship from an Advanced urse Practitioner for Dementia. Reviewers considered that the model of care being run required more extensive competences than those identified in the person specification, in particular, competences in differential diagnosis. Reviewers did not see evidence that nursing staff had, and were maintaining, the competences in the person specification. Wards were adequately staffed for the number of inpatients at the time of the visit (7 in patients with a bed capacity for 16 patients). Staff who met the visiting team felt that they had sufficient staff to manage the current number of patients and regular skill mix meetings were in place. Reviewers commented that two consultant psychiatrists may not be sufficient for the population of Dudley with dementia. There was no competence framework in place. A training needs analysis had been undertaken. WMQRS dudley dementia final report V doc 18

19 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments K-204 Crisis Advice Available 24/7 Specialist advice and support should be available at all times for service users and carers in crisis and for other agencies caring for service users in crisis. K-205 K-206 K-207 K-208 K-298 K-299 Support Services Dementia Pathway Coordinator A member of staff with responsibility for coordination of care for individual service users and for liaison with other services should be available. There should be arrangements for cover for absences of this member of staff. The member of staff should have particular expertise in: a. Dementia and its consequences b. Coordination of complex care packages c. Individualised budgets for care d. Advance care planning. Lead for oung Onset Dementia The service should have a nominated lead professional for the care of people with young-onset dementia. Lead for Acute Hospital Care The service should have a nominated lead professional with responsibility for liaison with local general acute hospital services. Cultural Change The service should run a programme which positively develops staff attitudes to empowering and enabling service users to take responsibility for their own health and care and live as independently as possible. Clinical and Managerial Supervision All practitioners should receive regular clinical and managerial supervision appropriate to their role. Administrative and Clerical Support Administrative and clerical support should be available. There were local authority processes for crisis advice. The mental health crisis team also accepted referrals of people with dementia. Dementia advisers and clinical nurse specialists were in post. /A o lead was identified. o lead was identified. There was no evidence of a cultural change programme. Administrative and clerical support was not available. Arrangements for meeting this QS for inpatients were not clear. Reviewers assumed that patients under CPA would have a coordinator. K-301 General Support for Service Users and Carers See QS K-101 WMQRS dudley dementia final report V doc 19

20 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments K-302 K-303 K-304 Brain Imaging Timely access to structural and functional brain imaging should be available, including timely reporting by a neuro-radiologist. Support Services Timely access to the following services to support the diagnosis, assessment and ongoing care of people with memory problems should be available: a. Speech and language therapy b. Dietetics c. Physiotherapy d. Pharmacy e. Consultants specialising in care of older people f. Consultant neurologists Social Care and Support The following services should be available: a. Befriending service b. Support group for carers c. Intensive home support d. Respite care Facilities and Equipment Brain imaging was not undertaken prior to diagnosis. Some patients were referred for brain imaging post-diagnosis. o guidelines were in place. Reviewers were told that clinical judgement was used on whom to refer for brain imaging and that ICE guidance was not always followed. K-401 Facilities for Physical Examination Facilities for physical examination of patients should be available, including equipment for undertaking a neurological examination. Assessments took place in people's homes. Memory clinics were not held. WMQRS dudley dementia final report V doc 20

21 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments Guidelines and Protocols K-501 K-502 K-503 Assessment and Care Planning Guidelines Guidelines on diagnosis, assessment and care planning should be in use. These should ensure involvement of service users and, if appropriate, carers in developing and agreeing the care plan. Guidelines should cover: a. Memory assessment, including imaging and physical examination (including neurological examination) b. Social care assessment, social care support and referrals c. Assistive technology assessment, assistive technology support and referrals d. Looking to the Future assessment and subsequent actions e. Carer s assessment, carer s support and referrals (if appropriate) f. Agreement of the Care Plan (QS K-105) with the service user and, if appropriate, their carer/s. Therapeutic Intervention Guidelines Clinical guidelines should be in use for each therapeutic intervention offered by the service. The guidelines should cover: a. Pre- and post-assessment counselling b. Pharmacological and nonpharmacological therapeutic interventions c. Approach to communication of the diagnosis d. Expected goals or outcomes e. Expected frequency of review. Referral Guidelines Guidelines should be in use covering the indications and arrangements for seeking advice from, referral to the following: a. Other mental health services (including those for older adults) b. Specialist services for people with learning disabilities c. eurology services d. Consultants specialising in the care of older people and frail elderly services (if available) e. Specialist investigations f. Genetic services Some of these assessments were undertaken but guidelines on the assessment and diagnosis process were not available. Guidelines for a, b, c or d were not available. E was met. Referral guidelines were not available. All but 'd' were available Localised clinical guidelines were not yet in place but were planned as part of the care cluster work. In practice, the therapeutic interventions were taking place. The dementia pathway was not clear and therefore referral guidelines had not yet been developed. WMQRS dudley dementia final report V doc 21

22 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments K-504 K-593 K-594 K-595 Transition from Other Mental Health Services Guidelines should be in use covering transition from the care of other local mental health services to the care of the Memory Service which should include: a. Involvement of the service user and, where appropriate, their carer in the decision about transfer b. Involvement of the service user s general practitioner in planning the transfer c. Joint meeting with the relevant mental health service in order to plan transfer d. Allocation of a named coordinator for the transfer of care e. A preparation period prior to transfer f. Arrangements for monitoring during the time immediately after transfer. These guidelines should have been agreed with the mental health service/s from which service users are usually transferred. Discharge Planning A discharge planning policy should be in use which ensures that a discharge plan is agreed with the service user and, if appropriate, their carer. The discharge plan should be communicated to the service user, their general practitioner and, if appropriate, their carer and should be recorded in their case notes. Mental Capacity Act and Deprivation of Liberty Safeguards A Trust policy on adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards should be in use. General Policies The following Trust Policies should be in use: a. Lone Working b. Medicines Management c. Health and Safety d. Risk assessment and management Guidelines were not available. Guidelines were not available. Evidence of compliance was not available. Evidence of compliance was not available. /A This QS is not applicable to in-patient services. The CPA policy covered discharge from an inpatient setting. A checklist was also in use with some prompts. WMQRS dudley dementia final report V doc 22

23 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments K-596 K-597 K-598 K-599 Safeguarding Policy A Safeguarding Policy should be in use. This should cover at least: a. Arrangements for investigation and, if necessary, referral of complaints and incidents relating to the care of vulnerable adults b. Expected staff training c. Who staff should contact if they have concerns about safeguarding issues d. Action to take when safeguarding-related allegations are made against a member of staff (or link to relevant HR policy). Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use. Palliative Care Guidelines Guidelines, agreed with the specialist palliative care services serving the local population, should be in use covering the management of patient with palliative care needs. End of Life Care Staff should be aware of local guidelines for end of life care, services available and how to access them. Evidence of compliance was not available. Evidence of compliance was not available. Evidence of compliance was not available. Evidence of compliance was not available. Information on how to report adult safeguarding concerns was easily visible in the ward area. o guidelines were in place, though good links with the Macmillan urses were reported. o guidelines were in place. WMQRS dudley dementia final report V doc 23

24 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments Service Organisation and Liaison with Other Services K-601 K-602 Operational Policy An operational policy should be in use which ensures: a. All service users are contacted within two weeks of referral b. Assessment of urgent referrals starts within 10 days of referral c. Assessment of routine referrals starts within 18 weeks of referral d. Assessment is completed within six months of referral e. A holistic assessment of the service user s needs is undertaken, covering memory, social care, assistive technology and Looking to the Future (QS K-501). f. Home assessments are undertaken when indicated g. Carers are offered an assessment of their own needs h. Information is offered to service users and carers (QS K-102 and K-106 to K-110) i. Multi-disciplinary discussion of the assessment and care plan for each service user and their carer takes place (QS K-603) j. A Care Plan is agreed with each service user and, where appropriate, their carer and a copy of the Care Plan is offered to the service user, their general practitioner and, if appropriate, their carer/s and is recorded in their case notes.(qs K-105) k. A named key worker is allocated to each service user (QS K-104) l. Responsibilities of the key worker m. Communication with the service user s GP. Memory Clinic Diagnosis and initial assessment services only: A memory clinic should be available at least weekly with at least: a. A consultant psychiatrist or appropriate other senior doctor specialising in the care of people with dementia b. A nurse or other health care professional with expertise in the care of people with dementia. There was no operational policy for the service. o clinics were held. /A o operational policy was evident. WMQRS dudley dementia final report V doc 24

25 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments K-603 K-604 K-605 K-606 K-607 K-608 K-609 K-610 Multi-Disciplinary Meetings Multi-disciplinary meetings should take place at least weekly to discuss service users and carers assessments and care plans. Liaison between Memory Services If diagnosis and assessment services are provided separately from follow up and ongoing support services: a. Written arrangements for liaison and communication between these services should be in use. These arrangements should be clear about the arrangements for re-assessment. b. An annual meeting should take place involving providers of dementia services within the health economy to review liaison arrangements and address any problems identified. Information for Primary Care The Memory Service should have circulated information to local primary care services to enable them to comply with QSs KA-103 and KA-501. Primary Care Liaison The service should have arrangements for liaison with the local Primary Care Dementia Liaison Worker (QS KA-601). Information for Long-term Care Services The Memory Service should have circulated information to local long-term care services to enable them to comply with QS KP-501. Long-term Care Liaison and In-reach The service should have arrangements for liaison with, and in-reach to, services providing long-term care for people with dementia. Acute Hospital Liaison The service should have arrangements for liaison with the link professional for people with dementia in the local general acute hospitals and should contribute to acute hospital training and development programmes Palliative Care Liaison The service should have arrangements for liaison with local palliative care services. Some liaisons took place informally and as part of the monthly monitoring meetings but formal arrangements were not in place. See main report. Some liaisons took place informally and as part of the monthly Dementia Service monitoring meetings but formal arrangements were not in place. See main report. /A This QS is not applicable to in-patient services. Primary Care Dementia Liaison Workers were not in post. The Dementia Service took responsibility for some aspects of this work. Information on the Dementia Service had not yet been circulated to long-term care providers. Primary care liaison worker was not yet in place. Letters were sent to GPs about admission. A social worker was attached to the ward and provided this function. As K-607. /A This QS is not applicable to in-patient services. Liaison was through the monthly Monitoring Group meetings. The Dementia Service was running as a pilot and these links had not yet been developed. /A This QS is not applicable to in-patient services. There were good working relationships with the Macmillan ursing service. WMQRS dudley dementia final report V doc 25

26 Dudley Dementia Service DWMHT Inpatients Ref Quality Standard Met? Comments Met? Comments K-611 K-612 K-699 Partnership Board Attendance The service should attend the local Partnership Board (or equivalent) with responsibility for improving services for people with dementia. Long-term Care Training and Development The service should contribute to training and development programmes for providers of long-term care for people with dementia (QS KZ-202). Primary Care Training and Development The service should contribute to primary care training and development programmes (QS KZ-299). The representation on the partnership board from the Trust was not clear. The Dementia Service had not yet contributed to the training and development of long-term care providers. Training and development for GPs was planned for June /A /A This QS is not applicable to in-patient services. This QS is not applicable to in-patient services. Governance K-701 K-702 K-703 Data Collection There should be regular collection of data and monitoring of: a. Referrals, including source of referral b. Individuals not considered appropriate for the service, including the reason why they were not considered appropriate and any onward referral destination or sign-posting c. Individuals not accepted by the service for some other reason d. Time from referral to start of assessment for urgent and routine referrals (QS K-601) e. Time from referral to completion of assessment (QS K-601) f. Waiting and reporting times for brain imaging, including reporting (QS K-302) g. Discharges, including expected care after discharge h. Minimum data set. Audit The service should have a rolling programme of audit, including: a. Audit of implementation of evidence based guidelines (QS K-501 and K- 502) b. Audit of primary care referrals, including whether pre-referral screening had been undertaken. Service Strategy The service should have a strategy for its development over the next three to five years. Data on a, b, c, d and e were collected. Information on f and g were not available. o evidence of compliance was available. Guidelines were not in place and so implementation could not be audited. The Dementia Service was running as a pilot and so did not yet have a strategy for its development. Some data were collected but not routinely monitored as required by the QS. Guidelines were not in place and so implementation could not be audited. A Trust wide strategy was available. WMQRS dudley dementia final report V doc 26