All Wales Improvement Network 31/3/09 Handbook for CSSIW inspectors – care homes for people with dementia

Some context – from our annual report Social services and social care in Wales are continuing to improve and there is growing confidence within the service. However there remain unacceptable variations in performance that need to be addressed. Rob Pickford, chief inspector

More from our annual report The development of a new approach to inspection will raise standards, improve quality and promote best practice. Effective partnerships with commissioners, positive partnerships with providers have resulted in good quality services

Annual report – care homes Progress by the care home sector is particularly noteworthy There are changing needs – evidenced by a 22% increase in variations of registration

Care homes – examples of improvement Quality of care plans Reviewing of care plans in consultation with service users Involvement of service users in decision making /wishes and feelings taken into account Respecting privacy and dignity

Further development needed Support and training for staff is key to ensuring a skilled and experienced workforce can meet complex and changing needs. Some improvement in training, but needs continued attention of providers Staffing levels -46% of reports had requirements (similar to last year) Staff competencies – 46% (66% last year) Supervision – 31% (50% last year)

The Handbook for Inspectors – context Original supplementary guidance 2003: since then we have had: New legislation Policy initiatives New research, reports, guidance Increased awareness of need to put service users’ well- being at the heart of service delivery – social/psychological needs as well as physical Centrality of person-centred care

Purpose of the handbook For inspectors – what to look for by way of up to date good practice Not exhaustive Useful at registration stage as well as in looking at existing homes

Background Definitions – clinical, social, “enriched” Prevalence – many people not receiving diagnosis Looking beyond deficits, working with strengths Staff skills, training – delivering more than good physical care Continuing involvement of carers, relatives Younger people with dementia

Assessment Stresses importance of diagnosis (NB this not itself a full indication of a person’s needs) Inclusion of people with dementia in assessments Considering possible future needs at time of initial assessment – will it be possible to avoid “moving on”?

Risk and risk assessment Actions and activities of service users – to try to open up possibilities rather than shut them down Assessments where care/intervention may carry risk (links to later section on dementia – compromised behaviours)

Statement of purpose/service user guide Opportunity for skilled provider to set out philosophy of care and how this carried through into practice Service user guide – inspectors can gauge how much communication needs of service users have been considered

Registration and variation “Mixed” settings : encouraging providers to develop/adapt services so that people with dementia can have a lifelong home where possible NB changes from previous guidance: 20% maximum of of people with dementia in mixed settings now removed Advice on not mixing people with dementia with people with functional mental illness now removed

Registration/variation (continued) When is dementia registration /variation needed? Non nursing: at diagnosis Nursing – if dementia needs predominate over physical needs (NB need to still ensure appropriate dementia care if person’s needs are predominantly physical) If a single service user – variation specific to that person. More than one – consider change of registration category

Service user plans / monitoring/ reviews Indicators for inspectors include: Service user perspective/participation Capacity Consultation with carers/relatives Communication needs and how addressed Preferred way of life, routines, life history Individual focus on social interaction, daily activity Maximising abilities, independence, focus on strengths as well as deficits Maintaining personality, identity

Core values (1): Privacy Indicators include: Staff able to gauge person’s need to be private vs. isolation/loneliness Personal care – staff supporting the person to complete the task themselves where possible

Core values (2) : dignity Indicators include: Clear philosophy to ensure maintenance of dignity Involvement of service user in decisions Recognition of the whole person

Core values (3): fulfilment Benefit of organised activities but also engagement of people with dementia at all times Indicators include: Inclusion of people in later stages of dementia Working with strengths Individual focus as well as general activities programme Record keeping

Core values (4): choice Emphasises value to service users of decision making, even at the simplest level Staff can do much to encourage

Dementia-compromised behaviours Can be needs-driven, meaningful to the person with dementia Emotions may be relatively intact, primary way in which the person relates The body – habits, gestures and actions as ways of communication Discussion of : oReduction oManagement oDealing with proportionately

Medication Discussion of non-pharmacological interventions for cognitive symptoms Anti-psychotics and alternatives Side effects Covert administration

Consent Greater clarity than in ’03 – thanks to Mental Capacity Act Affects all levels – e.g from care assistant making judgement about whether a person can agree to be bathed to issues around refusal of life-sustaining treatment A key point – no-one can be labelled “incapable” simply as a result of a particular medical condition or diagnosis

Financial matters Discussion of protection from financial abuse, capacity Inspectors should look for (e.g.): Separate accounts Recording Secure storage Record of valuables Clear guidance to staff

Environment (1) Varying approaches – low stress, domestic feel, own front door, degree of stimulation Specialist settings – small living units with at least two communal rooms Mixed settings – emphasis on well being of all service users

Environment (2) Discussion of (e.g.): Independence, access and variety Orientation Catering for people who choose to walk around Outdoor space Lighting Individual rooms – some suggestions Kitchens Bathrooms and toilets

Restraint Reducing the need Good practice Legal considerations including DoLS Environmental controls Technological surveillance (NB change from previous guidance: electronic tracking acceptable in some circumstances)