Background. ADASS welcomes the opportunity to contribute to this Inquiry

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1 Evidence from the Association of Directors of Adult Social Services to the All Party Parliamentary Group inquiry into the dementia care skills of social care staff supporting people with dementia. Background The Association of Directors of Adult Social Services (ADASS) represents Directors of Adult Social Services in Local Authorities in England. As well as having statutory responsibilities for the commissioning and provision of social care, ADASS members often also share a number of responsibilities for the commissioning and provision of housing, leisure, library, culture, arts and community services within their Councils. ADASS members are jointly responsible through the activities of their departments for the well-being, protection and care of their local communities and for the promotion of that well-being and protection through the use of direct services as well as the co-ordination of and liaison with the NHS, voluntary agencies, private companies and other public authorities. ADASS members have leadership responsibilities in Local Authorities to promote local access to services and to drive partnership working to deliver better outcomes for local populations. They participate in the planning of the full range of council services and influence Health Service planning through formal and informal Local Strategic Partnership arrangements. ADASS welcomes the opportunity to contribute to this Inquiry 1. What is the current readiness of the workforce to deliver personalised care to people with dementia and their families? Do you have specific evidence about workforce readiness on dementia? The implementation of both the National Dementia Strategy and the Putting People First agenda will impact significantly on the quality and availability of a workforce able to deliver personalised care to people with dementia. There is a strong correlation between training in personalisation and training in dementia. A workforce equipped with the necessary skills to provide person centred care will be more ready to take on the specialist skills that are required to support people with dementia. Both the National Dementia Strategy and Putting People First are in the early stages of implementation and as such, current progress is variable both across the country and between local services. There are however many examples of good and excellent practice around the country, a few of which are illustrated below. In residential care homes the best way to deliver personalised care is through good care planning for each person. Quantum Care, who provide residential care homes in Essex and Hertfordshire, have established training courses for all levels of staff including a Certificate in Dementia Care covering assessment and care planning aimed at those who will become champions for dementia in their residential homes.

2 Dementia mapping is also a tool that is used to deliver person centred care. Dementia Care Mapping (DCM) is a method designed to evaluate quality of care from the perspective of the person with dementia. It is used in formal care settings such as hospitals, care homes and day care. The process of using DCM involves briefing staff and clients about DCM in the area to be mapped, observing a number of people with dementia over a period of time and recording information about their experience of care, analysing and interpreting the data and then feeding it back to staff. This information is then used to draw up an action plan to bring about change and improvements. Dementia Care Mapping courses are currently provided by the Bradford Dementia Group St Helens council have commissioned a specialist home care service for people with dementia. Workers undertake an intensive training programme to equip them with the skills necessary to provide outcome focussed care. In addition the joint health and social care reablement team have all completed the Alzheimer s society accredited training and with additional training advice and support offered by psychiatric nursing staff and occupational therapists on a case by case basis. The council s in house home care team also have a rolling programme of Alzheimer s awareness training that they anticipate 100% of their staff will have completed by March The Carers Centre provides dementia training and learning resources for carers and an induction course on dementia is provided for Extra Care Housing staff. Gloucestershire County Council work collaboratively with the PCT and Mental Health Trusts, the Alzheimer s Society and independent sector providers, to coordinate a variety of dementia training programmes for health and social care staff, carers and volunteers across Gloucestershire. A dementia training pathway for care homes has been established enabling care home staff to access on site training, and an E- learning resource with ongoing support and leadership from identified Dementia Link Workers in each care home. There has been a huge uptake of training with resultant enthusiasm, confidence and understanding of person centred dementia care ultimately leading to improved services and a drop in referrals to the mental health trust from care homes. This service brings together workforce development and expertise and resources from the County Council, clinical expertise from Mental Health Trust, understanding and commitment from the independent and third sector and investment and support from the PCT. 2 / 3. What are the barriers to improving the skills of the workforce in dementia at a national, local and organisational level? What do you see as the solutions to delivering system wide workforce change in dementia skills? Dementia awareness Barrier The level of awareness of dementia and its impact amongst the public and professionals has historically been poor and a huge barrier to improving services. Solution The National Dementia Strategy seeks to address this and in recent times dementia has received far greater coverage in the national media. Increased awareness of the issues lead to higher public expectations and political will both nationally and locally to improve standards and services.

3 National training Barrier Although there are currently many examples of good training initiatives, dementia training has not generally been included in national core training programmes. Solution In order to ensure an appropriately trained workforce, the national workforce and training organisations must work together to ensure that dementia training is included as part of any national core training programmes for health and social care staff. Clear training pathways need to be established that are incentivised by minimum requirements and lead to appropriate skills for roles performed. These need to be broad enough to encompass the wide range of roles within the sector and not just add a higher education element at the advanced end. The introduction of recognised qualifications for care staff working with people with dementia would improve the skill base and status of this work and support the development of career structures. Local joint commissioning and provision of training Barrier People with dementia often require multi agency support from social care, health and housing, as well as support from informal carers. Lack of collaboration between health and local authorities in considering the needs of the local population, in addition to existing professional barriers and poor communication between organisations will work against improving the quality of dementia services. Solution At a local level Local Authorities and the NHS must work together to assess the future needs of their populations and commission and encourage the development of appropriate services to meet those needs. This is already happening through the Joint Strategic Needs Assessment (JSNA). The needs of people with dementia and their carers should be clearly mapped out and the expectations regarding training requirements of staff providing care to people with dementia should be made clear in the commissioning process. Joint cross sector training, also available for carers, would improve the quality of services delivered, helping to break down professional barriers and encourage productive working relationships. Provider staffing levels Barrier Lack of adequate staffing levels amongst providers can mean that there is a reluctance to release staff for training even if it is funded by the NHS or Local Authority. In addition managers or senior staff not fully committed to or engaged in training initiatives, may not support them. Solution Creative and flexible ways of providing training for example by providing E-Learning opportunities, an onsite training via Dementia Link Workers or Dementia Champion,

4 in addition to contracts that specify minimum training requirements, will encourage uptake. Training initiatives should recognise the importance of engaging managerial staff and include them at the outset. National and local workforce strategies Barrier Lack of measurable and comparable data on the local workforce to set a baseline and monitor progress is a barrier to improving services. A fragile workforce with a high staff turnover will have implications for the quality of service provided, the willingness of the employer to invest in training and the effectiveness of training programmes. Solution National Minimum Data Set (NMDS) enables local authorities to generate improved workforce intelligence to inform national strategic workforce planning and Integrated Local Workforce Strategies (InLaws). Through these processes the current make up of the workforce can be audited and strategies put in place to develop the workforce to meet future objectives including personalised care for people with dementia. Good local and national workforce strategies should be developed to ensure a stable, capable, well trained and motivated care workforce. Workforce strategies should take into account the quality of the staff required to provide care services to people with dementia and the remuneration levels that will be needed in order to attract staff of the correct calibre. Regulation and quality control Barrier Regulation requirements and contracts that are not specific with regard to minimum standards and expectations for dementia services may act as a barrier to improving the quality of services. Solutions Regulators responsible for the inspection and registration of services and Local Authorities who commission services need to clearly define what is required from dementia care services. Currently registration requirements are not specific in relation to dementia training however Local Authority commissioners may specify training requirements in their contracts and monitor compliance. Funding for training Barrier Lack of dedicated funding for dementia training Solutions There needs to be a commitment from Local Authorities, the NHS, partner organisations and providers to identify funding for joint training initiatives. There needs to be an acknowledgement in terms of funding that the skills of the workforce must to be maintained as new people come into post and continuously updated. Funding from Government would be welcome although short term funding over a one or two year period is not a long term solution.

5 4. What role can your organisation play to deliver a workforce which is better able to meet the needs of people with dementia over the next two years? The Association has nine Regional Networks in England which play an active and growing role in the implementation agenda set by the Department of Health. As well as meeting to discuss common regional issues as they arise within adult social care, Regional Networks play an increasingly important part in the new, DH-led Regional Presence initiatives, working closely with regional NHS colleagues and Government Offices on the important integration agendas that have emerged in recent years. The Association has ten Policy Networks including Networks for Older People, Mental Health and Workforce Development. ADASS also have an identified lead for dementia who sits within the Older People s Network. ADASS considers the implementation of the National Dementia Strategy to be a key priority for the Association in 2009 and has identified it as such in its Business Plan. The ADASS President s team, Regions, Older People s and Workforce Development Networks, will work both nationally and regionally to support the implementation of the National Dementia Strategy. The work will involve: to informing councils on key issues; contributing to the national implementation delivery programme; developing and disseminating evidence on commissioning, best practice and the efficient use of resources; influencing training across health, housing and social care; and engaging with enabling organisations and other key stakeholders (SCIE, Skills for Care, GSCC, the Alzheimer s Society, DH and provider organisations) to support the implementation. Other relevant priorities for the Association for 2009 are the implementation of Putting People First, Workforce Development, Safeguarding, Standards and Performance and the implementation of the National Carers Strategy. Improving services for people with dementia cuts across and will be embedded in each of these priorities. 5. What opportunities are there to develop the professional curricula in the next two years on dementia? As highlighted above there are many examples of good training practices across the country however developing nationwide professional expertise is essential and requires action in a number of areas. Action needs to be taken to look at vocational qualifications, recognising that the majority of care staff who support and care for people with dementia are unqualified staff. This can be done through developing competencies and minimum standards for practice through Skills for Care and Skills for Health. It also requires action looking at pre-qualification, competencies for qualifications and post qualifications course and continuous professional development. This requires discussions with those professional bodies and colleges that affect the curriculum, for example in social care, the General Social Care Council. It also requires leadership from the Department of Health in implementing its workforce development strategy, and through the SHAs in developing the NHS workforce.

6 6. What opportunities are there for collaboration with other organisations to improve the dementia care skills of the workforce and rates of diagnosis? Who would you like to see playing a role in this work? It will be essential to collaborate with other organisations to improve the skills of the workforce, and in social care the key national organisations are SCIE, Skills for Care, Skills for Health, the General Social Care council, and workforce development consortium. In addition, local collaboration across the range of stakeholders including the NHS, Local Authorities, provider organisations, the voluntary sector and carers groups is required. Local employers may also have a role to play regarding early diagnosis and supporting working carers and consideration should be given regarding how best to involve them in local training initiatives. The development of joint training in early recognition across all organisations and in particular health and social care agencies would contribute significantly to improving the early recognition and diagnosis of dementia. Not only staff providing specific dementia services but others providing more generic services to older people need to develop an awareness and expertise in recognising and working with early stage dementia that may not have been diagnosed. There also needs to be recognition that dementia is not an illness that confines itself to people over the age of 65. There are a small but significant number of people who develop young onset dementia and recognition and diagnosis within this age group is particularly poor. GPs will often be the first point of contact for these people and a greater awareness amongst GPs is needed. In addition Local Authorities and NHS Services must plan and provide appropriate services for this age group. There are good examples of collaboration and partnership working across the country. In the North West region the Five Boroughs Partnership, a specialist NHS Trust providing mental health services in partnership with Halton, Knowsley, St Helens, Warrington and Wigan councils, is committed to early identification of the disease and is looking to reconfigure services for older people with dementia. Appropriate skills training will be introduced alongside this initiative. The NHS East of England and ADASS Eastern Region have produced a comprehensive integrated commissioning strategy for dementia training that will be of interest to the All Party Parliamentary Group and is attached as Appendix A. Jenny Owen Vice President, ADASS Simon Williams Dementia Lead, ADASS March 2009

7 Summary statement for APPG on dementia 18 March 2009 Our national association is delighted that this group is giving attention to the workforce, since we all recognise that this is the single biggest factor which will shape the quality of care. My summary will outline 7 areas. Firstly, we recognise that the readiness of front line care staff is variable, due to factors such as turnover, status, a relevant training offer, and ability to be released for training. Potential solutions include dementia training being embedded in the new Qualifications and Credits Framework, the current campaign to raise the status of social care as a worthwhile career, and training which can be delivered in the workplace. Secondly, there is a wider range of staff who do not have a primary role in caring for those with dementia, but whose attitudes and level of awareness play a key role in recognising dementia and then in not excluding people with dementia from ordinary services. Examples include optometrists, pharmacists, and the whole range of local authority staff. We need to raise awareness of the condition and increase knowledge of the services available. Thirdly, dementia needs to command greater attention in professional qualifying and post qualifying training. For example, social workers need to attain a consistent level of knowledge and skill in assessing needs and working with users and carers to plan good outcomes. We are discussion with our own professional regulator the General Social Care Council on this point. Fourthly, a skilled and motivated workforce will need good leadership in the work setting, which will reinforce any training, inspire by example, and constantly find opportunities to improve practice. This is currently variable. Leadership may be a combination of the management team or from a designated champion. We need to find ways to find, nurture, train and support this talent Fifthly, we believe that the new emphasis on personalised care is highlighting opportunities for change. One example is some historic practice of commissioning care in a mechanistic task based way, rather than working with the service user and carer to agree the outcomes required, and then allowing the care provider to do what is necessary to achieve it. A second example is person centred planning, which recognises the personality behind the disability, listens hard to the person and those important in their life, and does what is possible to realise the person s goals. Sixthly, improvement continues to be held back in many places by the lack of integration between health and social care workers. A shared and common training offer across health and social care will go some way to improve workforce readiness, but this will have the greatest impact where there is integrated service delivery, in community provider services or in assessment and care management teams.

8 Finally, as an association we recognise our own leadership role, working alongside partner organisations. Two particular areas where we expect to make a contribution are training and commissioning of care. We need to commission training in a way which makes it accessible to front line staff and to local care providers, and building on existing excellent practice in some providers. There are good examples of where councils locally have worked with each other and with partners to do this. Regarding the commissioning of care, we all know that funding for care in general remains very tight and make no apology for seeking to stretch every pound, but we recognise the need to provide some incentives for care providers to invest in training for their staff. Can I thank this group once again for their attention to this subject and the opportunity to give evidence this afternoon. Simon Williams

9 APPENDIX A COMMISSIONING DEMENTIA TRAINING AND EDUCATION- AN INTEGRATED COMMISSIONING STRATEGY PAPER November 2008

10 CONTENTS Introduction Principles of Commissioning Dementia Training & Education p3 p4 i) Skills and Experience of Trainers p5 ii) Training Methodologies iii) Learning Outcomes iv) Organisational Responsibilities Cost Considerations References p5 p6 p7 p8 p8

11 INTRODUCTION The importance of improving the standards of knowledge and awareness of dementia amongst health and social care professionals was first reflected in the Dementia UK report (Alzheimer s Society 2007) and in the National Audit Office report (NAO 2007) and has been a consistent theme throughout the listening and consultation events for the National Dementia Strategy. People with dementia and their carers have asserted that this is imperative if the quality of care and service given is to improve. This need to improve standards is being driven forward in the Strategic Health Authority s (SHA) vision Towards the Best Together (2008), the NHS next stage review (2008) and the National Dementia Strategy (NDS 2008). Recommendation 2 of the NDS is: An informed and effective workforce for people with dementia with the outcome: All health and social care staff involved in the care of people with dementia to have the skills needed to provide the best quality care in the roles and in the settings where they work. To be achieved through effective basic training, and continuous professional and vocational development in dementia. Investment in dementia training and education programmes will not only improve the quality of care for people with dementia and their carers, it can also improve morale amongst the workforce and help to address some of the recruitment and retention challenges faced by employers. This document should be read in conjunction with the overall integrated commissioning strategy for dementia (Recommendation 9 of the NDS), produced by the SHA and Association of Directors of Adult Social Services (ADASS) in Sept This strategy aims to promote an integrated model of training and education for all staff from all sectors, including medical staff, the benefits of which are: Standardised and improved level of knowledge across organisations Consistency in the quality of care across the region Cost effectiveness as less duplication and opportunity to pool resources Specialised knowledge will improve quality of information given to the public and people living with dementia and their carer/s Specialist knowledge of unpaid carer/s Promoting independence and avoid admission to hospital Networks can be developed for ongoing support Input to staff can be coordinated with input to managers to support staff training For the purpose of this document the use of the word carers refers to unpaid carers and the use of care staff refers to paid carers from all sectors

12 PRINCIPLES OF COMMISSIONING DEMENTIA TRAINING AND EDUCATION Primary Care Trusts (PCTs), Local Authorities (LAs) and partner organisations will need to apply the following principles to commissioning dementia training and education: A whole systems integrated approach based on a clinical, biophysical and social outcomes for people living with dementia and their carers Training and education needs to have a clear practical focus relevant to the work of the learners where possible addressing real needs of real clients Training and education should be commissioned to support continued and sustained learning, rather than ad hoc programmes that have little sustainable impact on quality of care Training and education should be progressive and mapped to a skills escalator, for example, the NHS skills escalator Training and education programmes should be accredited, or externally verified, and linked to vocational awards wherever possible, for example, National Vocational Qualifications (NVQ s) Training and education programmes should include a range of teaching methodologies that can adapt to individual learning styles, including long distance learning Commissioned training and education programmes should be made available to carers Training and education is evidence based and contemporaneous and should meet regulatory standards Mandatory specialist vocational courses on dementia should be commissioned for all care staff who work directly with people with dementia Mandatory training and education around dementia, raising awareness, skills, attitudes and dignity should be an integral part of foundation training and education of all health, social care and third sector staff and commissioners should work with foundation training and education organisations to ensure this is implemented A workforce must be available with the skills to manage younger people with dementia and people with learning disabilities and dementia and training and education should be available that targets the needs of these specific groups of people Equality- training and education should be sensitive to the needs of people from different cultural and ethnic backgrounds Training and education must adhere to legislation on mental health, The Mental Health Act (2007), Mental Capacity Act (2005) and the Singles Equality Act (2008) The approach to training and education takes account of existing and developing ethical frameworks, to facilitate and assist the management of dilemmas occurring when making decisions about dementia care Commissioners will expect all training and education providers to demonstrate how all training and education programmes promote the dignity and respect of the individual Training and education at a team level is preferable for sustained quality improvements Training and education providers need to ensure organisational managers understand the reasons for training and education and commit to supporting staff through the training and education process and subsequent change in practice.

13 Commissioned training and education programmes must be independently evaluated for impact on quality of care for people with dementia and their carers. Training and education should influence regulatory standards i) Skills and Experience of Trainers Commissioners will ensure that training and education providers have the necessary knowledge and skills to provide training and education on dementia. Trainers/Educators should be able to provide evidence of their experience of working with people with dementia and their carers and will need to demonstrate specific knowledge of different care environments. Trainers/Educators should have, or be prepared to work towards, an accredited training/education qualification, for example, the Alzheimer s Society Approved Trainers Scheme. Trainers/Educators will evidence commitment to ongoing professional development. Trainers/Educators and training and education programmes will need to be externally evaluated on an annual basis. This could be achieved through external peer review and through a learner s evaluation report that is externally prepared, or internally prepared and externally verified. The learner s evaluation report will be based on learner evaluation forms, although peer review could include confidential interviews with a random sample of learners. Quality Indicators: 100% of commissioned training and education organisations to provide evidence of all trainers/educators qualifications and experience/references in an annual report to commissioners by April % of all trainers/educators to have, or be working towards, an accredited training/education qualification by April Evidence of this to be supplied to commissioners in the annual report Annual report on the accessibility, responsiveness and quality of training and education provided, which is submitted to the commissioners detailing an action plan for service improvement by April 2010 Commissioners to keep a register of trainers/educators by April 2010 ii) Training methodologies Commissioners should ensure that training and education providers can evidence that a range of teaching methods are available, and accessible, to learners to meet individual learning styles. An integrated training and education approach will provide opportunities for people to learn in their own teams, separate groups or as individuals and be available in a variety of locations, including a learner s own home via distance and internet learning programmes (the latter is intended as an option for carers). Teaching methods can include, but are not limited to: Case study analysis, using a variety of media, for example video analysis Experiential learning, using learners own examples or using the experiences of people with dementia and their carers

14 Direct involvement from people with dementia and their carers (Journal of Dementia Care August 2007). Any expenses incurred should be met by the training and education organisation, for example, travelling and private home care costs whilst carer away from home Role play / Objective Structured Clinical Examination (OSCE) Didactic learning where applicable Self assessment against competencies Reflective practice Train and educate care staff to become trainers/educators within their organisations Peer review, for example, small care homes could work together Quality Indicators: Annual report on the accessibility, appropriateness, variety and quality of the teaching methods offered to learners, which is submitted to the commissioners detailing an action plan for service improvements by April Record the numbers of in house trainers/educators within each organisation by April 2010 iii) Learning outcomes Skills for Care ( have produced a knowledge set for dementia, with learning outcomes, that has been developed in conjunction with Skills for Health (see appendix 1). Commissioners should broadly base their expectations of training and education providers to achieve these learning outcomes with the following additions: Training and education should promote independence through the personalisation programme, individual budgets, direct payments, assistive technology, housing, leisure and intermediate care Training and education should highlight the specific needs at specific stages of dementia, for example the early, middle and later stages of dementia Training and education should include the understanding of perplexing behaviours and the management of the environment, particularly in relation to visual and spatial awareness Training and education should focus on prevention of crisis Training and education should focus on enabling people with dementia and their carers to choose how they would like to be cared for at the end of life Training and education should promote the individuality of a person with dementia by enabling learners to understand how to apply life stories and dementia care mapping Training and education should enable learners to support people in the early stages of dementia, for example, post diagnostic counselling Training and dementia should have a focus on the specific needs of younger people with dementia, people with alcohol related dementia and people with a learning disability and dementia Training and education will provide a range of ethical frameworks to support decision making. Understanding of risks and that taking risks can be integral to quality of life

15 Commissioners should ensure that the overall outcome of any training and education programme will be to equip learners with the necessary practical skills and knowledge that has a proven impact on the quality of services provided to people with dementia and their carers. Simply ensuring that learning outcomes are met is not enough to demonstrate improvements in quality of care, so commissioners must ensure that training and education providers have the means to assess the practical impact of the training and education provided. This may be achieved in a number of ways: Dementia care mapping, QUIS, SOFI Learner self assessment and organisational assessments of learners practice Learning log diaries with evidence of improvements in practice Assessment of practical competencies by training and education organisation Peer review Feedback from people with dementia and their carers Quality Indicators: 100% of commissioned training and education organisations to provide evidence that curriculum s meet the required learning outcomes by April % of commissioned training and education organisations to provide evidence, in the annual report to commissioners, that training and education is having a practical impact on the quality of care provided 90% of all foundation courses to include training and education on dementia and dignity by Sept 2010 Annual service user and carer satisfaction survey on the accessibility, responsiveness and quality of service provided. Surveys should be conducted independently of the service provider and an annual report submitted to the commissioning organisation detailing an action plan for service improvement. This is the responsibility of the care provider, not the training and education provider, as detailed in the overall integrated commissioning strategy for dementia. By April 2011, a reduction in the use of PRN medication to control behaviour as the workforce become more skilled in managing challenging behaviour. * Improved training and education will enable organisations to achieve the other quality indicators that are detailed in the overall integrated commissioning strategy for dementia. iv) Organisational responsibility Organisations, including residential care, that are commissioned to provide care for people with dementia have a responsibility to ensure that they have a trained, educated and skilled workforce that can meet the needs of people with dementia and their carers, in accordance with the National Dementia Strategy. Commissioners should ensure that organisations have an appropriately trained, educated and skilled workforce.

16 Each organisation should promote the use of dementia champions to provide leadership and ongoing support to people who have undertaken training and education and to ensure that change in practice is ongoing and sustained. A dementia champion does not have to be a senior manager anyone should be able to take on this role. Quality Indicators: All staff who may have direct contact with people with dementia and their carers to have received dementia training and education within 5 years Providers to record the number of staff employed in each service who have received training and education on dementia. Evidence of dates and course attended to be provided upon request. Organisations to record the number of dementia champions within the organisation and report to commissioners in the annual report (aim for each care environment to have at least one dementia champion by April 2010) Cost considerations: Currently, the statutory organisations that provide training and education to independent residential homes charge a small fee for each participant. The fee, which is below the market value, is usually in the region of 30 per participant to cover costs. Commissioners will need to consider how to incorporate this costing structure when commissioning from statutory providers. Commissioners should recognise the importance of third sector services and ensure that voluntary service providers achieve full cost recovery for the services provided References: Alzheimer s Society (2007) Dementia UK. Department of Health (2008) Draft National Dementia Strategy. HMSO East of England SHA (2008) Towards the best together. EML Hayes, K (2007) Devising the poetry of dementia pp 28 Journal of Dementia Care Knapp et al (2007) as cited in Alzheimer s Society (2007) Dementia UK. Abba Litho, London National Audit Office (2007) Helping People through mental health crisis:the role of crisis resolution and home treatment services.hmso Appendix B

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