improving care in care homes in the south west

8/9/2019 Improving care in care homes in the South West

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www.southwestdementiapartnership.org.uk 1

Improving care in care homes in the South West

Introduction

In recent months there has been heightened

public interest about the care of people with

dementia living in care homes. Sustaining high

quality support to people with dementia, 24

hours a day, 7 days a week is huge challenge. It

requires relentless enthusiasm and commitment

from staff who are insightful and skilled. It also

requires care homes have good support from

local health and in reach services.

ManyCare Quality Commission inspection

reports pay tribute to the dedication and hard

work of front line care home staff. There are

many homes which strive to provide good care

and many examples of people with dementia

being supported to remain active and involved in

daily life. However the quality of life of

experienced by some people living in care

homes can be poor and the media has raised

serious concerns about the attitude, competenceand behaviour of some people working in the

care home industry. Concerns about training in

dementia has been highlighted in a number of

reports and forums, including the All Party

Parliamentary Group report 'Prepared to care:

challenging the dementia skills gap' on the

dementia workforce and at the Public Accounts

Committee hearing Train to Gain: Developing

the skills of the workforce 21 January 2010.

Enlightened care is possible. It can be uplifting

and enriching and a source of positive energy. It

is made possible when people with dementia areplaced at the centre of the life of a care home

and when they continue to be people living a life,

and are not just passive recipients of services.

The difference between poor and enlightened

care is about vision and values, and the belief

that people with dementia can continue to live

well in care homes. It is based on the principle

that people at any stage of dementia are still

people, and should be valued and recognised as

such. It is founded person centred care, on the

principle and that people with dementia have

both human and legal rights; rights to be treated

with dignity and respect, for their best interests

to be served and the right to enjoy social

relationships.

The difference between poor and enlightened

care is the belief that a care home can be a

happy and fulfilling community, rich in human

experience and rewarding for the people living in

then home, the staff who work there and the

relatives who visit.

Some owners, managers and staff truly

understand and embrace this. Others do not.

This is often the fundamental difference between

excellent and adequate care. All the paperworkand training in the world will never help those

South West Dementia Partnership

Discussion paper April 2010
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who dont truly embrace person centred care to

bridge the gap.

This discussion paper aims to draw together a

lot of evidence about care homes in the South

West. It highlights how managers, staff,

commissioners andCare Quality Commission

inspectors can contribute to improving the

quality of care in care homes.

Improving care in care homes in the South West Discussion paper


1. Best and worst: what is the difference

This section compares samples of reports from the best and worst care homes in the South West. It also

includes the conclusions of a focus group which was held in June 2009 to share learning about improving

care homes, and identifies areas of innovative and best practice.

2. Market analysis

This section provides a breakdown of the level and types of provision across the South West comparing

the region with the rest of the country. It then provides a detailed analysis of the quantity and quality of

provision across the 15 council areas.

3. Fees analysis

This section compares the arrangements for calculating fees and the levels paid across the region. It is

based upon a sample of 8 of the 14 combined council and Primary Care Trust areas in the South West.

4. The South West National Dementia Strategy Review

This section considers the findings of a review which was conducted across the South West in 2009 to

determine the readiness of health and social care communities to carry forward the National Dementia

Strategy. It considers the findings in respect of Objective 11 Improving care in care homes, and the extent

to which local social and health care communities are responding to the original recommendations in the

Strategy.

5. Future plans

This section explains how the South West Dementia Partnership will be supporting implementation of the

National Dementia Strategy in respect of care homes.

6. Questions to ask yourself

This section provides self assessment tools to help people to reflect on what they should or could do to

improve care for people with dementia. The tools provide sets of Questions to ask yourself, designed for

care home managers and providers, health and social care commissioners and Care Quality Commission

inspectors. The questions are drawn directly from the findings in this discussion document.

It is intended as a resource to inform, challenge,

prompt and promote ways to improve the

experience of people living with dementia in care

homes.

The discussion paper has six sections looking at

care homes in the South West from a number of

different perspectives, and sets out action

people might take to improve the quality of care.
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Sir Gerry said, we face a

battle against apathy,complacency and lowexpectationsThat is not the case everywhere. There are

many examples of excellent work and willing

minds. However we could do better and it is

hoped that this contents of this document and

the questions to ask will help people in the

South West to respond to Sir Gerrys challenge.

1.Can Gerry Robinson Fix Dementia Care

Homes? broadcast on BBC Two at 2100 GMT

on Tuesday 8th and Tuesday 15th December

2009.

Background April 2010

Working together to promote living well with dementia 3

Fixing dementia care in care homes

In the Autumn of 2009 two television

programmes were broadcast in which

businessman Sir Gerry Robinson was invited tofix dementia care in care homes. [1]

The programmes primarily focussed on

examples of poor care in care homes. The

programmes did not tell the whole story, and

many people felt they were unbalanced and

painted an unnecessarily negative picture of an

industry where many work hard and strive to do

their best. Undermining the public image of care

homes does not help people with dementia and

their carers. They need to feel both positive and

confident about the option of using a care home

when life becomes impossible to sustain at

home. Nor does it help with attracting and

retaining a good quality workforce where people

should feel proud of working in care homes,

supporting people with dementia.

The programmes did however raise somepowerful questions. They also showed that

excellent care is possible, and it is possible to

improve care homes which are failing by a

change of mindset and strong leadership. This

discussion paper includes a number of quotes

from the programmes.
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1. Best and worst: what is the difference

In order to answer this question a small study

was undertaken in May 2009. This provided the

basis for further discussion in a focus groupwhich included providers, care home managers,

regulators, commissioners and carer

representatives.

The study was based on a simple textual

analysis of dementia care home reports

downloaded from the Care Quality Commission

websitewww.cqc.org.uk in May 2009. A sample

of reports for 10 homes covering each rating,

poor, adequate and excellent was analysed,

that is, 30 reports in total. There was an equal

balance between nursing and residential homes.

The analysis did not focus on the traditional

standards and regulations, but sought to identify

recurring themes across reports. Data was also

collected in respect of bed numbers, fees

charged and whether a registered manager was

in post.

What quickly emerged from this study was that

there was little apparent difference between

themes arising in nursing homes and residential

homes. Indeed there was as much reference

about health related care (for example, diabetes,

pressure area care) in residential care as there

was in nursing care homes.

It was also apparent that the homes were highly

varied with some purpose built, some with wide

mixes of category and specialist wings. Most

were private institutions; the better homes

appeared to be run by not-for-profit trusts. Two

council homes were included in the sample, one

poor, and one excellent. However detailed

analysis of provider type was not undertaken as

it was not always clear from the report what type

of provider was concerned.


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errors with medication administration.

In six out of ten homes there was little or no

provision of meaningful activity. In some homes

there appeared to be no activities taking place.

People were observed as being bewildered,

bored and disengaged.

In over half the homes low staffing levels and

lack of training were mentioned. Lack of training

in dementia care was particularly evident.

In half the homes, lack of choice and control was

noted as was lack of dignity and respect paid to

people living in the homes. Clear instances were

cited of people being overlooked, ignored or

spoken down to. There were a number of

examples of institutional practice, for example,

everyone being given a plastic beaker with

diluted cordial.

In four out of ten homes nutrition and food were

cited as poor, and lack of any choice was often

noted.

What was particularly striking was that seven out

of ten of these homes had very poor

environments. They were often described as

shabby, in disrepair, smelly and lacking in

investment. Reference was made to stained and

ripped sheets, poor decorative order, confusing

layouts, poor signage, lack of assisted bathing,

and homes being cold. In some, extremelyserious health and safety issues were

highlighted including very hot unguarded

radiators and scalding water.

Poor environments are symptomatic of poor

vision and investment by the provider. Its

consequences are dispiriting for the people who

live in, work in and visit the home. Research

Poor homes

How have we allowed

our elderly to be treated

this way?The typical poor home failed in a number of

areas, and the combination of these made for an

impoverished experience for those living and

working in the home, with high risks to health

and well being.

Nine out of ten poor homes had weak care

planning processes, and staff who were clearly

unaware of the needs of people living in the

home, notably healthcare needs and support

needs, for example to assist people who

became distressed or anxious. Particular

mention was made of staff not being given

guidance on how to respond to anxiety or

challenging behaviours, and examples weregiven of how staff responses had escalated

peoples frustration and distress.

Care plans did not reflect the actual needs of the

people, they were not up to date, not clear, not

accessible, and were said to be of little value to

staff. Care plans were described as being not

person centred or based on peoples wishes or

relatives views. Significant risks associated withbehaviour were not anticipated or managed.

In six out of ten homes there was poor attention

paid to critical health care needs. A range of

examples of basic neglect were cited, including

pressure area and wound care, dental hygiene,

blood tests not being done, and poor catheter

care. In four out of ten homes there were serious

1. Best and worst: what is the difference? April 2010

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suggests that the environment can a large

impact on peoples behaviour, and that enabling

environments result in both better outcomes for

people living in care homes, less dependency on

staff intervention and can be more efficient to

run. See for example, Chapman, A., Jackson, G.

and Macdonald, C. (2009)What Behaviour?

Whose Problem? A guide to responding to the

behavour of people with dementia. Dementia

Services Development Centre, Stirling.

In six out of ten homes there were no quality

assurance measures in place. In five of the ten

homes there was no registered manager,

references being made to managers having left,

recruitment activity and temporary cover

arrangements.

Adequate homes

You can get by with

adequate care that it fails

to address the point. That

life could be so much

better

There was a wide of range of adequate homes.Some appeared generally quite good but hadone or two significant failings, for example inrelation to health and safety or medication

management which had brought their rating

down. In some homes most people appeared

were well cared for, but the home had failed to in

respect of the care to one or two people with

more complex needs.

Other homes had a broader range of concerns

but with less serious consequences than those

noted in poor homes.

A number of adequate homes appeared to be

improving with previous requirements (often

care planning) having been addressed since the

last inspection.

In seven out of ten homes care plans were

noted to be a problem. Plans were not person

centred nor did they reflect individual needs. For

example, staff in some homes did not know the

preferred names of people living in the home,

which is particularly significant when

communicating with someone with dementia. As

with poor homes, some care plans failed to

provide staff with skills and strategies for

responding to complex behaviours.

Concerns about healthcare needs were less

prominent (as indicated three out of ten homes),

although medication concerns were still noted in

five of the ten homes.

Choice and control featured as an issue in three

care homes, and dignity and respect in one

home.

The need to improve activities was noted in four

adequate homes.

Little mention was made of concerns about

staffing levels or staff training. Environmentalconcerns featured in only two homes, and the

need for quality assurance only featured in one

home.

As with poor homes, half appeared to be

without a registered manager.


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Excellent homes

It requires

passionate relentless

leadership leadership

is about rising above

the day to day, and

taking people withyou.The reports for excellent homes painted a

completely different picture to that of poor

and adequate homes. Excellent homes

appeared be lively places where staff were

proactive in meeting needs. They were

homes that had benefited from investment, had

energy and were places where the people living

in the home came first. They were also generally

well run.

In eight out of ten homes there were positive

comments about care planning: Very clear

guidance; Staff know the needs for people;

Staff know what to do. Plans tended to be

person centred (six out of ten mention this) andholistic. Critical needs were identified and

addressed. One example was a coloured coded

system to direct staff to key areas of need.

In five homes health care was highlighted as

being excellent. Health care needs were seen to

be protected and references were made to best

clinical practice, for example the Gold Standards

Framework in Care Homes.

Despite being excellent, three homes had

requirements relating to medication although

these appeared to be refinements and

improvements rather than necessary as a result

of serious failings.

Communication with and support for relatives

was often mentioned in excellent homes. Some

excellent homes provided private areas to meetand some encouraging email communication

with families, for example enabling downloading

and printing pictures for people living in the

home. There was also mention of engagement

with the local community. These themes were

not apparent in poor and adequate homes.

Excellent homes were very strong on activity

provision. This was often described as
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innovative, stimulating and individualised with

mention of variety, one-to-one time and

availability of private space. Examples of good

activity provision were cited in seven of the ten

homes.

Nine of the ten homes were commended for the

dignity and respect being shown to people. The

prevailing ambience was significant, with

inspectors noting laughter and banter and staff

supporting people to use their own skills as

much as possible. Six of the ten homes were

commended for promoting choice and control,

and for reflecting people's views and interests in

the running and management of the home.

It was particularly striking that nine of the ten

homes had excellent environments. Some were

purpose built or had been carefully adapted.

Some clearly enabled people to have access to

safe gardens and communal areas which

encouraged socialisation. Mention was made of

homes providing a calming atmosphere. Words

used included, welcoming, light, comfortable,

airy, fresh, and clean.

Food and nutrition were commended in five of

the ten homes, choice and healthy, balanced

diets being noted.

Staffing arrangements were commended in eight

of the ten excellent homes. Staff were

described as enthusiastic, trained and

competent.

All the excellent homes appeared to have

registered managers in place. Strong

leadership was cited in four reports, with

additional mention of good teamwork and

support for staff. Effective quality assurancewas noted in three homes.




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Good care does not

only come down to

money.

From a business point

of view, care given toresidents has to be the

priority. There is no

downside from any point

of view in running these

services brilliantly.The inspections

The inspection reports were fairly consistent in

their approach. However some were more

sensitive to assessing whether care was person

centred, especially whereShort ObservationalFramework for Inspections (SOFI) or an expert

had been included.

Some inspections and reports, particularly in

poor homes, emphasised the importance of

basic, safe care as this was clearly seen as a

priority for concern.

Other findings:

Size of home

In the sample, poor homes had 36 beds onaverage, (range 12 to 68), adequate homes 35

beds (range 12 -64) and excellent homes 50

beds (range 18 102). Many of the bigger,

excellent homes however had separate

dementia wings or annexes so it is hard to draw

any firm conclusion. However, these figures

suggest that with investment larger homes can

be managed in a way which delivers good

outcomes for people with dementia.

Price

This analysis is simplistic as the rates charged

by homes vary considerably on the basis of

rooms and levels of need, and whether people

are privately or publicly funded. However figures

show that high fees do not guarantee quality.There were some very poor, expensive homes

(for example in old stately buildings), two of

these charging the highest non-nursing fees in

the region, one in excess of one thousand

pounds a week.



Type Range Average Sample

Poor350

1050620 10

Adequate381

766540 10

Excellent380

895631

6

(4 figures

missing)
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Driving improvement

The findings of this study were presented to a

small focus group in June 2009. The group

included managers and providers nominated byinspectors for having improved care homes for

people with dementia, inspectors with an interest

in dementia care, commissioners and two carer

representatives one of whom acts as an expert

by experience for the Care Quality Commission

and assists with inspections. The group was

asked to consider a range of topics.

What does good care look like?

The answer appeared to be quite simple.

Good care is recognising and supporting people

with dementia as individual people, putting them

at the centre of the life and routines of the

home. It is providing whole person care based

on knowing and understanding a persons

history and their life before dementia.

Good care is about empowering staff, providing

them with skills and encouraging them to think

creatively, and enabling staff to spend time with

people living in the home rather than being

focussed on completing domestic tasks.

Good care is about working with feelings; to

quote one manager

Care without feelingsbecomes cold

Good care is about using and sharing good

practice and having strong leadership.

Good care is not isolated, but is integrated with

mainstream community services, with strong

links to multidisciplinary teams and pharmacists.

Good care anticipates end of life needs, and

prepares for this in advance and in line with

people's wishes.

Good care supports good quality ongoing

relationships with carers and promotes their

inclusion in the life of the home.

Commissioning practice

Providers said that commissioning

arrangements tended to be inflexible and were

in favour of variable fees. They said that

contracts tended to be based upon units of

care, not individual needs and this created a

tension when trying to deliver personalised care.

Funding streams appear to be locked inseparate health and social care silos, which

meant that people with increased care needs

moved into nursing care at increased marginal

cost when a smaller increase in funding and

community nursing support could have enabled

people to stay in their existing residential home.

They felt that the cost benefits of appropriate

funding and support of less intensive care

needed to be understood. For example,

providers felt more end of life care could be

provided in non-nursing care homes.



The focus group was then asked to consider a

number of questions. The responses have been

collated and summarised below. They help to

identify both the barriers to delivering good care

in care homes, and potential solutions.
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Providers felt commissioners tended to

commission to a price, not to quality, and there

was a need to model funding at a level which

enabled sufficient staff, particularly nursing staff,

to be on duty.

Care home managers felt that unrealistic

expectations were placed upon them, that they

had to cope because that was what they were

paid to do. They said care managers

sometimes placed people with particularly

complex needs in homes not equipped to meet

them, and that these placements quickly

destabilised their homes.

Commissioners said that better diagnosis of

cognitive impairment would assist in informing

placement suitability and assist in making

appropriate placements.

Commissioners felt that commissioning was

increasingly reflecting the wishes and

expectations of people using services and

carers. They believed that contract monitoring

was improving and there was a greater



emphasis on quality. They reported increased

flexibility in using health and social care

budgets.

Primary and secondary healthcaresupport

Care home managers said they struggled with a

lack of specialist dementia assessments which

means staff are working in the dark without an

effective diagnosis prior to placement; GPs just

guess.

Some managers reported close, beneficial

working relationships with local community

mental health teams. They noted that effective

communication with community mental health

teams can offer valuable insights into the life of

the resident before their dementia, and assists

homes in appropriate care planning.

In one home the local consultant held regular

clinics in the home and this was said to have

reduced the number of admissions to hospital.

Some residential homes said that the variation in


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the availability of community nursing support is a

problem.

Initiatives being pursued in Gloucestershire

attracted interest, for example, the No Barrier

referral scheme which gives care homes direct

access to secondary care support like dieticians

without the need to go via a General

Practitioner. Gloucestershire also has a multi-

disciplinary care home support team available to

support those homes where concerns had been

noted.

Pharmacists were seen as having a key role in

ensuring that medication is reviewed regularly,

and specialist audits were commended.

Regulation

In every care home Ihave been in we lockresidents in as if it's a

foreign country protecting

people with dementia from

life we have consigned

them to a safe butstagnant life, locked

inside

I don't think safety

should be placed abovethe quality of people's

livesManagers and providers said that there was a

genuine fear of the regulator which made

managers defensive and risk averse. There was

a perceived a lack of consistency and mixed

messages from inspectors particularly in respect

of risk assessments and encouraging creativity.

Managers said that some inspectors did not

engage with people living in services, or observe

care practices when undertaking inspections.

Some inspectors are only interested in the

paperwork. This meant good care practice went

unrecognised. In general it was felt there was

excessive auditing of factors which were not

outcome related.

Both inspectors and managers suggested that

there was a lack of oversight and quality

assurance of inspections, and an overemphasis

on the numbers of inspections being completed

rather than the quality of the inspections. They

thought that there is also a need to develop

dementia awareness amongst some inspectors.

Inspectors thought that greater emphasis should

be placed on ensuring services had registered

managers, and that greater regulatory pressure

should be applied on providers to ensure timely

replacement of managers.




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Staffing

What is relevant is staff

morale; it's the secret of

success in business

where staff are so directly

responsible for the care of

residents.I wouldn't risk tostaff morale for the sake

of a few pence it's

about caring for your staff,

thinking about them,

bringing them

alongsideCare home managers said that skilled staff was

a significant factor. The lack of reliable, specific

training on good dementia care was a major

issue. Training needed to be funded and

accessible.

Managers said that overuse of agency staff in

some care homes was a major problem as this

disrupted continuity of care. They felt there was

over reliance upon staff from different countries

whose spoken or written English may not be

strong enough to ensure reasonable

communication. This caused a range of

problems from following instructions and care



plans to ensuring effective communication, both

between staff and people living in care homes

and within staff teams. They felt it was an issue

which needed to be addressed, but that people

were anxious about raising it for fear of being

labelled racist or discriminatory.

Managers made a number of recommendations

based on their experience:

advertising for and recruiting staff who had

a heart for the job rather than expecting

care work experience

writing job descriptions which includedinvolving people living in care homes as

part of people jobs, (for example gardening)

providing training incentives for staff

reviewing and restructuring shift patterns.

the main focus of the

day is connecting with

people with dementia; it's

so hard to get staff to

unhook from the task; its

their security blanket

David Sheard


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Care home managers felt that some staff liked to

remain in a secure comfort zone and avoided

spending time with residents by choosing to

remain in established routines. They said many

staff have a genuine fear and unease about

talking to people with dementia. This often

related to a lack of skill in communicating with

people with dementia, or simply not knowing

anything about them, their lives, preferences or

communication needs.

Carers and relatives issues

Managers felt that in general care homes did not

understand the experience or support needs of

carers when their relatives moved into

residential care. Managers stressed the need for

carers to receive information, and the

importance of carers induction and education.

The relationship between carers and relatives

and the care home can be very complex and

challenging. There are potential relationship

problems with most families, including problems

with carers letting go, jealousy, grief, projectionand underlying denial about the diagnosis of

dementia.

Addressing and clarifying expectations of carers

is an important part of establishing an effective

relationship and responding to carers emotional

needs.

Care planning

There's an awful lot still

going on inside ... you can

get to it by stepping back

and look at the world

through their reality; forget

logic and reason and

listen to what the person

is experiencingAlzheimers Society trainer

Managers said the lack of any information about

a persons background or life history was a real

issue, and that despite efforts this was often

hard to fathom. Obtaining reliable information

from the person with dementia was a challenge,

and families often regarded their family life as

private. One manager remarked that often they

only really found out about a residents life when

they attended their funeral. They were left

feeling that the persons life in the care home

had been a lost opportunity; so much more

could have been done to enrich the persons life

if the information had been available before the

person died.




15/40



Managers recognised that establishing peoples

wishes, choices and feelings was not easy. It

was therefore important to use observation to

find out what works, what people respond to,

and ways of engaging people. Using life story

books had proved helpful in some homes in

researching peoples needs and discovering

which activities were likely to be enriching and

which should be avoided.

Managers said care planning systems tended to

be clinically based and that there was a

tendency to use stock phrases. This meant the

individual didnt come over.

Managers recommended person-

centred care planning systems

which focussed on ability.


16/40

Activities versus living a life

How can we stand by

and watch our elderly die

of boredom? helping to

keep people alive rather

than helping them to

live

We are just stagnant we expect to getignored, it kills your

spirit

Quarter of a millionpeople living in carehomes, and whatstruck me straightaway

was that people were just

sitting there and not doing

anything ... nothing

happened in their lives

that mattered any more,

they are just sitting in thisroom like broken vessels

doing nothing

At 4 pmthe residentswere more getting restlessbut after six hours of

staring at a wall, is that

surprising?




17/40


18/40

Environment

Managers felt that homes did not always have to

be purpose built but that investing in buildings

made a real difference to peoples wellbeing andbehaviour. In one home, a simple low cost

extension which joined up the communal space

between two buildings had transformed the lives

of people living in the home. People were more

able to move around freely and as a result had

more exercise. This had meant the use of night

time sedation had significantly reduced. Other

managers had noted similar outcomes by

enabling people to have access to gardens.

One manager believed in creating an

environment which had opportunities for

discovery, and had found that routinely

swapping things around his home had increased

peoples interest and encouraged exploration.

Managers were insistent that architects should

never be allowed to go it alone, and

recommended that people with experience ofrunning homes needed to be actively engaged

throughout the design process.

Management

Care home managers believed that risk

management was often the most significant

issue in determining the culture of care homes.Risk averse homes tended to be institutionalised

homes. They said managers needed to have the

confidence and ability to take on and manage

risks and have support and understanding from

regulators. They also said managers needed

confidence in challenging barriers to change and

skills in changing staff attitudes.

Managers felt that poor management practice

was primarily due to ignorance, complacency

and lack of support. This was reinforced by

working in isolation, sometimes spending many

years working in just one home; you only know

what you know. Managers said they had

benefited from a range of opportunities including

sharing good practice between services,

external consultancy, cross-service audits, being

a member of a provider association and

accessing best practice through conferences

and publications.

Providing structured peer support to failing

homes was proving to be a particularly

successful strategy which had been developed

by Gloucestershire Care Providers Association

and the County Council.

Care home managers felt there was a lack of

appropriate training and development

opportunities for managing care homes for

dementia. There were unique demands;

dementia sense is not common sense.

One provider emphasised the need for long-term

succession planning to avoid reactive

appointments, stressing the importance of

developing strength and depth in leadership so

that if a manager moves on there are people

who can step into their shoes.




19/40

2. Market analysis April 2010


2. Market analysis

This analysis is based upon the information

available on the Care Quality Commission

websitewww.cqc.org.uk as of 6 December2009. It is based on the number of homes rather

than the number of placements. The tables in

the Appendix provide a detailed breakdown.

There are just under 1500 care homes across

the South West providing care to older people

and people with dementia. Of these, 57% of the

homes are registered to provide care to older

people, 10% are specifically registered to

provide care to people with dementia, and 33%

are registered for both older people and

dementia.

34% of homes are registered to provide nursing

care.

The vast majority (84%) of homes are run by

private providers. 11% of homes are run by

voluntary organisations and charities, and 5% bylocal authorities.

50% of the region's homes are small to medium

size having less than 30 beds. 85% have less

than 50 beds.

The Care Quality Commission rates the quality

of care homes as either poor, adequate,

good or excellent. These judgements aremade against published criteria.

Poor homes are those where there are

serious risks and significant concerns about

the well-being of the people living in the

home.

Adequate homes are those where there

may be risks and concerns but these are

being managed.

Good homes are those where people are

safe and well cared for, and excellent

homes are those that provide high-quality

care which is person centred.

It is generally accepted that the quality of care in

poor and adequate homes should not be seenas acceptable, and that care services and that

commissioners should seek to ensure people

only receive care in homes rated as either good

or excellent.

In December 2009, 17.6% of care homes in the

South West were graded as poor or adequate.

This is in line with national average (17.5%) and

is a drop from the regional figure obtained inMay 2009 (22%).

3.1 % of homes were judged to be poor.

There is little apparent variance between nursing

homes (17.4%) and non-nursing homes

(17.7%).

16.4% of homes registered only for older people

were judged as poor or adequate, however this

increases slightly to 18.5% of homes providing

care to both older people and people with

dementia, and 21.2% for homes specifically

registered for dementia care.

Looking at this breakdown more closely, whilst

there is little variance across the types of home

for non-nursing care, but there is marked

variance for nursing homes.

Only 14.4% of nursing homes registered to older

people only were rated as poor or adequate,

however this figure increases to 20.0% of those

registered to provide care to older people and

people with dementia and 28.6% for nursing

homes exclusively registered to provide

dementia care.
http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.cqc.org.uk/http://www.cqc.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.cqc.org.uk/


20/40

Although the number of dementia specialist

nursing homes is relatively small, these figures

indicate that nursing homes looking after people

with dementia and deserve particular attention.

This appears to be supported by anecdotal

evidence about the prevalence and nature of

safeguarding concerns in nursing homes. There

does appear to be a particular difficulty in

providing effective physical and mental health

nursing care and support to people with

dementia.

Extending the analysis to individual Council

areas highlights a number of variations in terms

of quantity and quality of provision.

Some Councils have a high number of older

people and dementia care homes in their

locality, the highest being Devon (289) others

have comparatively few (Swindon, 25). The

scale of the commissioning and contracting

challenge therefore varies enormously.

When considering the current estimates for the

over-65 populations, the rate of care home

provision per thousand also varies across

communities. This analysis is based on care

homes rather than bed numbers in so it cannot

be used to assess capacity. However it does

indicate that in some communities there is a

greater relative choice than in others, and it

highlights the density of care homes in some of

the traditional seaside resorts.




21/40

2. Market analysis April 2010


Comparing areas with small geographic spread, in Swindon there are 25 homes for an older

population of 27,200, this in Torbay there are 80 for a population of 31,600, and in Bournemouth 77

homes for 31,900.

Comparing areas with large rural geographic spread, in Devon there are 289 homes for for an older

population of 164,000 whilst in nearby Dorset there are 128 homes for an older population of

101,700.


22/40



It is difficult to assess the level of dementia-

specific provision across the region as some

homes are jointly registered for older people and

dementia, and in some of these homes there are

specific wings or annexes providing dedicatedcare in other jointly registered homes the needs

are not separated.

However the level of dedicated dementia care

home provision does appear to vary across

Council areas. In Poole 9 (24.3%) of the 37 care

homes are specifically registered for dementia,

whilst in Devon 16 (5.5%) of the 289 care homes

have a specific dementia registration.

There are significant variations in the quality

rating profiles across Council areas. Some have

a low rate of poor and adequate care home

provision, as in North Somerset (7%), South

Gloucestershire (8%); whilst others havesignificantly higher proportion, as in Dorset

(26.5%), Gloucestershire (23%). The tables in

the Appendix provide an opportunity to identify

areas of concerns, for example whether there is

a higher proportion of homes specifically

registered for dementia which all rated as poor /

adequate. For example 6 out of the 11 homes

registered specifically for dementia care in

Gloucestershire are rated poor or adequate,similarly 5 out of 16 in Devon and Cornwall are

rated poor or adequate.


23/40

3. Fees analysis April 2010


To support adequate matching of capacity and demand commissioners could consider

Is there an over or under supply of care home capacity in your area taking into account your

geography? What are the reasons for this, and the implications of this? Is the range of

specialist dementia provision sufficient?

Are there underlying reasons or specific care home groups which account for the levels of

poor and adequate care provision? How might these be addressed?

Compared with other Councils, do you have sufficient capacity in your commissioning and

purchasing teams to oversee the number of services in your area?


24/40



3. Fees analysis

An analysis of care home rates charged in the

South West

This analysis aimed to find out what rates were

being paid by different areas in respect of older

people (OP) and dementia care (DE).

A simple questionnaire was sent out to 14

localities, and 8 replied. The questionnaire

asked for rates of fees for different placements,

OP and DE, nursing and non-nursing, and

whether recognition was given to different levels

of need and different quality ratings.

Responses were received from Poole and

Bournemouth, Bristol, Dorset, Gloucester, North

Somerset, Swindon, Torbay, Devon.

From the responses received and some of the

discussion which took place, it emerged that:

commissioning practice is highly varied andit is difficult to make comparisons or

generalisations. Some commissioning

arrangements could not easy be translated

into answers to these questions;

a number of Local Authorities are currently

restructuring their pricing tariffs and are

seeking guidance on yardsticks;

providers have enormous difficulty indrawing up business plans if they are near

boundaries and delivering to Local

Authorities with very different pricing

arrangements;

pricing is sometimes based on a calculated

fair price for care, but it is also often

driven by historical arrangements or market

factors, particularly demand and supply,

and importantly the local ratio ofprivate/Local Authority placements.

Given the wide range of variables at play and

the very different approaches it is difficult to

produce a simple analysis.

However, the following results do provide a

context for considering different approaches.

1) The basic price of care homes

These figures exclude any additional payments

which might be made for quality.

Personal care

The price for a placement of an older person

with personal care needs only ranges from 307

to 500. The average when taking lower needs

banded fees into account is 367, with higher it

is 402.

For people with dementia the range is 329 -

500. The average based on lower needs is

418 and higher 441.

Six of the areas paid an enhanced rate for

dementia care, two did not. This ranged

between 22 and 112 per week across both

personal and nursing care, on average being

52 per week.

Nursing homes

The price for a placement of an older personwith nursing needs ranges from 438 to 650.

The average when taking lower needs banded

fees into account is 508, with higher it is 534.

For people with dementia the range is 477 -

680. The average based on lower needs is

534 and higher 569.

The 680 rate is an exceptional rate for people

with dementia who require nursing care and

have challenging needs.


25/40

Section April 2010


2) Paying for increased levels of need

Two Councils did not have a system for paying

for different levels of needs. One other paid an

additional 3% exceptional needs increment.

Of the remaining five, four Councils had a three

banded needs based system and one a two

banded system which was only applied to their

older person, non-nursing homes.

Banded payments ranged from an additional

premium of 34 - 88, the average being 62

and were similar across nursing and non-nursing

care.

3) Paying for increased quality

Only three Councils paid increments for

improved quality.

For homes rated good the additional premium

ranges from 4 to 15 a week, the average

being 8.

For homes rated excellent the addition was

6.20 - 20, the average being 13.

Other factors

In one area a geographic weighting was applied

ranging from 16.70 - 33.40 which was

primarily a reflection of significant differentials inland and property prices across the area, and

the need to ensure people who were publicly

funded could remain living within their local town

where care home prices were higher.

There were also some additional complexities

due to historic block placement purchases and

the use of declared beds which were held

available for Council use.


26/40

The table below shows the number of

communities adopting National DementiaStrategy recommendations identifed in objective

11 and those adopting other strategies.



4. The South West National Dementia

Strategy Review

Between May and July 2009 a review was

undertaken across the South West, lookingindepth at the progress being made in taking

forward the individual objectives of the National

Dementia Strategy.

Number of communities adopting National Dementia Strategy recommendations identifed in

objective 11 (out of 14 communities)

Commissioning specialist in reach support from mental health teams 8

Promoting the identification of senior leads for improving dementia care 6

Promoting the appropriate use of antipsychotic medication 4

Provision of guidance to care home staff on best practice 4

Number of communities adopting other strategies

Targeting Care Quality Commission ratings 8

Supporting care homes staff training 6

Specialist Care home GAP analysis 5

Improving General Practitioner support to care homes 4

Establishing pathways pre- and post- care homes 3

Developing care homes quality metrics 2

Introducing person centred planning 2

Developing dementia service specifications 1

Use of quality / specialist fee incentive 1

Establishing a specialist dementia provider forum 1

Making link to Deprivation of Liberty Safeguards and safeguarding 1

Promoting dignity in care 1

Improving care home environments 1


27/40

4. The South West National Dementia Strategy Review April 2010


In respect of objective 11 Improving care in care

homes, the review found that Councils and

Primary Care Trusts place heavy reliance on

Care Quality Commission ratings. A number of

Councils and Primary Care Trusts were noted to

be targeting poor care homes, offering support

particularly with staff training. A number of

Councils were strengthening their contracts with

care homes and increasing their contract

monitoring. The review found that systems for

reviewing people living in care homes and

funded by Councils varied across the South

West, some people being regularly reviewed,

others not so.

The review found that whilst there were some

good examples of efforts being made to raise

standards, this was often a reaction to crises

rather than a proactive approach to improving

care across the care home sector. The review

found that the amount of training available and

the level of NHS in-reach support services

including mental health, nutrition and continence

care varied considerably across the South West.The reviewers also noted that good nursing

homes tended to have strong links with primary

health care team nurses.

The review included feedback from people with

dementia and carers. Their comments

suggested that their experiences of the quality of

care in care homes were much less positive

than that reported by inspectors. Carers wereparticularly concerned about the lack of

meaningful activity and stimulation provided in

care homes.

National Dementia Strategy

recommendations

Clearly much emphasis is being placed on

developing in-reach mental health services, andthe benefit of such support was noted by

managers who attended the focus group. They

indicated that there would be some value in

assessing the effectiveness of the various

models of providing such support.

Less than half the communities seem to be

supporting the development of lead dementia

specialists in care homes. Although the objective

is aimed at providers, it is an area where

commissioners can exert a lot of influence and

which could have very significant impact in the

delivery of care and in changing care home

cultures.

Gloucestershire has put substantial effort into

developing a certified training programme for

lead care workers and developed support

networks for dementia care home leads.Anecdotally this is already showing very

substantial benefits.

There is potential conflict between schemes run

by Councils and those by larger care homes

corporate providers. This will need to be

anticipated and managed.

Placing clear contractual expectations on carehomes in respect of having dementia leads who

receive best practice training and updates is an

achievable opportunity for commissioners. It

could also form part of the quality assurance

analysis and rating assessment undertaken by

Care Quality Commission.

Four communities identified the need to focus on

medication practice within care homes with an

emphasis on the reduction of antipsychotic
http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.cqc.org.uk/http://www.cqc.org.uk/http://www.cqc.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.cqc.org.uk/http://www.cqc.org.uk/


28/40


29/40


30/40

5 Future plans

In the South West key public agencies and the

Alzheimers Society have formed a partnership

to support the implementation of the NationalDementia Strategy.

Details of its activities can be found on the South

West Dementia Partnership website at

www.southwestdementiapartnership.org.uk



Representatives of this group will be visiting

each health and social care community over the

coming six months to provide support andadvice in respect of delivering their local action

plan, and will be discussing their plans to

improve care homes.
http://www.alzheimers.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.alzheimers.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/


31/40

5. Future plans April 2010


There will also be a range of activity across the

region including:

Self assessment questionnaires based on

the findings of this review sent to all care

homes, commissioners and Care Quality

Commission. This will encourage people to

think about the part they might play in

improving the experience of people living in

care homes.

Promotion of link dementia workers in all

care homes for older people and dementia

and the development of a social networking

site for this group to receive support. Letters to all care homes including the

Social Care Institute for Excellence

postcard which explains how to access the

excellent on line training materials it has

developed for care home staff.

Collection of care home positive practice

examples which will the featured in the

South West Dementia Partnership website

and bulletin.

Further work with provider organisations

and commissioners on developing an

agreed quality assurance framework and

person centred care planning.

Presentations and training at care home

provider events across the region.

TheSouth West Dementia Partnership is very

keen to receive feedback, suggestions,

concerns and examples of good practice.

If you would like to give us feedback, send us

examples of good practice or ask a question

please contact us via

[email protected].
http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.cqc.org.uk/http://www.cqc.org.uk/http://www.cqc.org.uk/http://www.scie.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/mailto:[email protected]://www.southwestdementiapartnership.org.uk/http://www.cqc.org.uk/http://www.cqc.org.uk/http://www.scie.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/mailto:[email protected]


32/40



6. Questions to ask yourself

The task of improving care in care homes rests with a wide range of people, all of whom have a

responsibility to achieve improvements. To help people to reflect on what they should or could do to

improve care for people with dementia there are sets of Questions to ask yourself, designed forcare home managers and providers, commissioners andCare Quality Commission inspectors. The

questions are drawn directly from the findings in this discussion document.

Care home managers and providersYes; I know this because

..

No; But I am planning

to..

1

Our care home has a member of staff

who is identified as our dementia

champion. They know about best

practice and are an inspiration to others.

2

Our care home keeps up to date, uses

other peoples ideas and is aware of

best dementia practice.

3

Our staff are well trained and motivated

and understand the importance working

from the perspective of the person with

dementia.

4

All our staff know the preferred name of

each person living in our home. They

know about their wishes, background,

their critical care needs and how to

support them if they become distressed.

5

We positively support relatives and

involve them in the life of the home and

in helping support family members.
http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.cqc.org.uk/http://www.cqc.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.cqc.org.uk/


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6. Questions to ask yourself April 2010


Care home managers and providersYes; I know this because

..


to..

6

In our home people with dementia are

supported to do things which they find

rewarding. Our home buzzes with

activity.

7

Our care home has a quality assurance

system which is includes careful

assessment of the experience of

people living in the home

8

We are confident in taking managed

risks. We believe in supporting people

to remain active.

9

We have the right ethos; We enjoy the

challenge of looking after people withdementia, we like problem solving and

being creative.

10

Our care home is cheerful, safe and

interesting. It enables people to move

freely inside and outside and provides

cues to help people find their way.

11

Our homes manager is well supported,

and has a clear vision about how good

dementia care should be delivered.

12

We have a strength and depth in the

leadership in our home and others who

can step into the managers shoes


34/40



Health and social care

commissioners

Yes; I know this because

..


to..

1

Our contracting arrangements require

that care homes have an identified

member of staff who is recognised as

the dementia lead / champion.

2


that care homes keep up to date about

best dementia practice.

3

Our contracting arrangements place

minimum expectations on staff training.

They ensure that staff know what

dementia is, how it is experienced, and

the importance working from the

perspective of the person with

dementia.

4


that care homes have a robust quality

assurance system, which includes an

assessment of the experience of

people living in the home.

5


that care homes have effective

management arrangements in place.

6

People requiring placement are

properly assessed and placed in care

homes which are able to meet their

needs.

7

We have commissioned effective

specialist mental health in reach

support, available to all our care

homes.


35/40



Health and social care

commissioners

Yes; I know this because

..


to..

8

We have commissioned effective GP

and primary health care support to our

care homes.

9

We have the right range and balance

of care homes to meet needs of people

with a range of dementia conditions.

10

We have sufficient commissioning

capacity to manage and oversee our

care home market.

11

Our contract specifications, monitoring

arrangements and quality assurance

systems are based upon person

centred outcomes.

12

Our workforce development plan

recognises the need to provide

effective dementia training to care

home staff across council run and

independent sectors.

13

We have an effective joint health and

social care strategy to provide support

to failing homes.

14

Our funding arrangements provide

some flexibility across health and

social care and can respond to

changing levels of need.


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Care inspectorsYes; I know this because

..


to..

1

I am not risk averse. I give priority to

people in care homes being able to live

a life and accept that as a consequence

there will be potential risks.

2

I have a good understanding of the

needs and experience of people with

dementia. My judgements are based onthe perspective of people with

dementia.

3

During inspection site visits I spend at

least a third of my time directly with or

observing the people who live in the

home.

4

I am confident in judging the quality and

effectiveness of staff competence and

training.

5

I approach inspections with positive

expectations and ambitions for peoplewith dementia.

6I am up to date about good dementia

practice in care homes.


37/40



Care inspectorsYes; I know this because

..


to..

7My inspection practice is quality

assured by others.

8

When judging care homes I give weight

to the importance of appropriateactivity and stimulation.

9

I have a good understanding of the

National Dementia Strategy, its

expectations and its implications for me

as an inspector.

10

I am confident that the overall ratings I

award are a fair reflection of the quality

of life of people living in the home.

11

I am know which homes do not have

registered managers and am able to

apply effective pressure to ensure aregistered manager is identified without

undue delay.

In my inspection practice I am particularly pleased with.


38/40



Council

Totalhomes

OP

OPDE

DEonly

%D

Eonly

TotalhomesAdeq

/Poor

OPAdeq/Poor

OPAdeq/Poor

DEAdeq/Poor

POPPI>65/000

Homes/000

%A

deq/poor

Bath and North

East Somerset37 28 7 2 5.4 4 4 0 0 31.2 1.19 11%

Bournemouth 77 48 10 19 13.0 15 9 3 3 31.9 2.41 19.5%

Bristol 67 44 13 10 14.9 13 7 4 2 55.2 1.21 19.5%

Cornwall and Isles

of Scilly168 60 82 16 9.5 35 14 16 5 114.2 1.47 21%

Devon 289 139 134 16 5.5 47 22 20 5 164.3 1.76 16%

Dorset 128 96 24 8 6.2 34 23 8 3 101.7 1.27 26.5%

Gloucestershire 132 99 22 11 8.3 30 20 4 6 109.4 1.21 23%

North Somerset 86 64 9 13 10.5 6 4 2 0 41.7 2.10 7%

Plymouth 69 28 35 6 8.7 14 5 9 0 40.7 1.69 20%

Poole 37 19 9 9 24.3 5 2 1 2 29.3 1.26 13.5%

Somerset 150 103 37 10 6.7 28 15 10 3 110.2 1.36 19%

South

Gloucestershire49 34 9 6 12.2 4 3 0 1 42.3 1.15 8%

Swindon 25 13 10 2 8.0 3 2 0 1 27.2 0.91 12%

Torbay 80 29 46 5 6.2 10 5 5 0 31.6 2.53 12.5%

Wiltshire 100 38 49 13 13.0 19 5 10 4 82.7 1.21 19%

1013 1.46 17.8%

Overview of older peoples and dementia care homes across the South West

Appendix


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Appendix April 2010


Totals OP only DE+ OP DE only

NationalNumber 10,544 4702 4676 1166

% - 45% 46% 11%

Adequate / poorNumber 1842 753 874 216

% 17.5% 16% 18.7% 18.5%

South West regionNumber 1494 852 496 146

% - 57% 33% 10%


% 17.6% 16.4% 18.5% 21.2%

Size OP+DE OP only DE only Total ~%

90 10 1 0 11 1

Type OP+DE OP only DE only Total ~%

LA 25 33 11 69 5

Private 413 704 121 1238 84

Voluntary 56 102 13 171 11

Total 494 869 145

~% 33 57 10

Breakdown by size of care home

Breakdown by provider of care home

Comparison of older peoples and dementia care homes in the South West with national figures

Breakdown between nursing and non-nursing care homes in the South West

Totals OP only DE+ OP DE only

NursingNumber 512 326 130 56

% 34% 64% 25% 11%


% 17.4% 14.4% 20.0% 28.6%

Non NursingNumber 982 526 366 90

% 66% 54% 37% 9%


% 17.7% 17.7% 18.0% 16.7%


40/40

A partnership to promote living well with dementia


More information

If you would like to give us feedback, send us

examples of good practice or ask a question please

contact us [email protected].

South West Dementia Partnership website

www.southwestdementiapartnership.org.uk provides

further information about the review along with

examples of innovative practice. For example,

Devon have made their action plan to implement

the National Dementia Strategy available for other

communities to refer to

www.southwestdementiapartnership.org.uk/impleme

ntation/devon/

SCIEs Dementia Gateway

www.scie.org.uk/publications/dementia/ produced

by the Social Care Institute for Excellence (SCIE)

offers high quality information, video and training

programmes. There is in depth advice about

establishing communication and managing difficult

situations. You can also use materials on the site to

update your learning portfolio!

The Alzheimers Societywww.alzheimers.org.uk

offers a wide range of fact sheets, studies,

discussion forums, advice and sources of support.

There are also some valuable tips for nurses

which are suitable for a wide range of professionals

www.alzheimers.org.uk/countingthecost

Dementia Information Portal is a Department of

Health website, which follows the implementation of

the National Dementia Strategy. It offers information

to anyone with an interest in improving services for

people with dementia.

www.dementia.dh.gov.uk

Dementia Services Development Centre (DSDC)

ia an internationally recognised centre forexcellence in dementia research and training for

health and social care professionals working with

people with dementia.

www.dementia.stir.ac.uk

Innovations in Dementia supports people with

dementia to become more involved and have a say

in anything that affects them.

www.innovationsindementia.org.uk

Dementia Voice is a dementia centre of excellence

whose work challenges traditional thinking about the

way dementia services are designed and delivered.

www.dementia-voice.org.uk

A partnership to promote living well with dementia
mailto:[email protected]:[email protected]:[email protected]:[email protected]://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/implementation/devon/http://www.southwestdementiapartnership.org.uk/implementation/devon/http://www.southwestdementiapartnership.org.uk/implementation/devon/http://www.scie.org.uk/publications/dementia/http://www.scie.org.uk/publications/dementia/http://www.alzheimers.org.uk/http://www.alzheimers.org.uk/http://www.alzheimers.org.uk/countingthecost/http://www.alzheimers.org.uk/countingthecost/http://www.dementia.dh.gov.uk/http://www.dementia.dh.gov.uk/http://www.dementia.stir.ac.uk/http://www.dementia.stir.ac.uk/http://www.innovationsindementia.org.uk/http://www.innovationsindementia.org.uk/http://www.dementia-voice.org.uk/http://www.dementia-voice.org.uk/http://www.gosw.gov.uk/mailto:[email protected]://www.southwestdementiapartnership.org.uk/http://www.southwestdementiapartnership.org.uk/implementation/devon/http://www.southwestdementiapartnership.org.uk/implementation/devon/http://www.scie.org.uk/publications/dementia/http://www.alzheimers.org.uk/http://www.alzheimers.org.uk/countingthecost/http://www.dementia.dh.gov.uk/http://www.dementia.stir.ac.uk/http://www.innovationsindementia.org.uk/http://www.dementia-voice.org.uk/http://www.alzheimers.org.uk/http://www.southwest.nhs.uk/http://www.dh.gov.uk/http://www.gosw.gov.uk/http://www.gosw.gov.uk/http://www.alzheimers.org.uk/http://www.southwest.nhs.uk/http://www.dh.gov.uk/http://www.gosw.gov.uk/

improving care in care homes in the south west

Documents