Draft as of Feb 2011

Transcription

1 ANNEX C South West Dementia Partnership Improving Care for People with Dementia or Mild Cognitive Impairment While in Hospital (Target date for achievement set by SHA as end of March 2012) GHNHSFT Self assessment and Action Plan Draft as of Feb 2011 Work is developing, led by Trust Dementia Working Group to identify action plan priorities and target deadlines Trust Dementia Working Group Core Membership Safeguarding Adults Dementia Hospital Standards Annex C Page 1 of 41

2 Maggie Arnold(MA) Dr Ian Donald (ID) Dr Mohammed Lynne McEwan() Nursing and Midwifery Director (Executive Lead) Dementia Strategy Senior Clinical Lead Asghar(MA) Dementia Strategy Clinical Lead Senior Nurse/Safeguarding (Group Facilitator) Vanessa Roberts(VR) Lead Nurse / Matron General and Old Age Medicine (Medicine Division) Gillian Keates (GK) Lead Nurse / Matron Trauma and Orthopaedics (Surgical Division ) Steve Shelley(SS) Mental Health Liaison Nurse / Tim Framer (TF)Mental Health Liaison Nurse Lead Mental Health Liaison Team Denise Barr(DB) Palliative Care Specialist Nurse Rachel Minett(RM) - Eli Hanman (EH) Jeanette Welsh(JW) Paul Hooton(PH) General Manager / Julie Garnham(JG) Divisional Nursing Director Specialist Nurse Acute Pain Team Practice Development and Educational Support Nurse Un-Scheduled Care Team Associate Director Professional Development Nursing and AHP (Diagnostics and Specialties Division) Jan Stroud(JS) Senior Sister Julie Bruce- Watts(JBW) Staff Nurse Ryeworth Ward Sister Out Patients Department Gill Brook(GB) Trust Head of Patient Experience Karen Easton(KE) Gynaecology Nurse Consultant ( Women s and Children s Division) Expert Reference Hospital Learning Disability Liaison Nurse Team(HLDLNT) Martin Pratt(MP) Trust Head of Pharmacy Maureen Dunn(MD) Senior Clinical Information Analyst Carol McIndoe(CM) Trust Equality Officer Liz Dawes(LD) Clinical Audit Manager Annea Stephens(ASt) Clinical Coding Manager Helen Vaughan(AV) Dementia Programme Manager NHS Gloucestershire Jan Sketchley Kay(JSK) Patient First System Manager Project Lead PAS plus Project Kate Jeal(KJ) Trust Communication Team Andrew Seaton(AS) Trust Head of Patient Safety Trust Bed Management Team(BMT) Jon Burford(JB) Trust Head of Nursing Cancer and Palliative Care Safeguarding Adults Dementia Hospital Standards Annex C Page 2 of 41

3 Standard 1: People with dementia are assured respect, dignity and appropriate care LEVEL 1 1. Develop a ward champion role with specific responsibilities for delivery and auditing of standards and for training. Compliance with model developed across South West. Trust Dementia Working Group representatives Trust Safeguarding Adult Strategic Board Representatives Trust Matrons Trust Essence of Care Ward Link nurses Dementia Training and Education Strategy Trust Dementia Local Incentives Scheme Audit Programme 2010/2011 Trust Safeguarding Adult Audit Programme 2011/2012 Trust implementation of the Learning Disabilities Link worker role Align with South West Model when launched Develop a ward/dept link role and a dedicate training programme, include training on auditing Reflect model implemented for LD Link Worker role MA PH TF/ SS 2. There is accessible laminated literature on the ward, including these standards and information about future planning, that can be understood by patients with early dementia and that can be used by their carers. There is a variety of literature for Review of literature by clinical champion and ward champions with Alzheimer s Society and or relevant patient group. Safeguarding Adults Dementia Hospital Standards Annex C Page 3 of 41

4 staff on the ward linking with training and development programmes within the hospital. Trust Dementia Strategy being updated, when relaunched will be available in easy read and on Trust Internet Home page Carers Strategy Carers Leaflet Patient Bedside Information Pack Health Resource Room at GRH Trust Learning and Development Intranet site Trust Patient Information Policy Literature being developed by SHA Dementia Partnership SHA patient and staff literature to be launched when released by SHA Link to Patient Bedside Information Pack Strategy Update Trust Internet Home page link to Dementia Information for patients and Carers Information to be available in Patient Information Resource Centres at GRH - develop system for CGH -align with Trust Learning Disability Strategy action plan Develop audit proforma and capture of patient feedback on availability of patient and carer information Trust E-Learning Programme to link to staff and patient information GB PH TF 3. The care plan is person-centred as evidenced by observation of staff interaction with patients. Patients and carers feedback demonstrates high levels of satisfaction with care. Minimum standard = 90%. Direct ward observation by auditors. Patient Experience Tracker and/ or compliments/ complaints. Safeguarding Adults Dementia Hospital Standards Annex C Page 4 of 41

5 Trust Dementia patient specific Care plans implemented Oct 2010 Patient with known Dementia, Patient with disorientation and Memory loss Survey of Carer of patient with Dementia implemented Oct Trust Survey Volunteer targeting this group of carers to actively seek feedback on experience Carer listening event planned for Feb/March 2011 Implementation of the Living Well with Dementia Handbook and the This is me Document- Trust Group leading on this action Develop system to consistently capture patient and carer feedback on experience align with Trust Learning Disability Strategy action plan- Easy Read patient /carer comment cards Training and Education Strategy Promote staff understanding and application in practice of person centre care for person with Dementia Embed use of the Living Well with Dementia Handbook and the This is me Document Dementia ward/dept Link training Strategy GB VR PH Safeguarding Adults Dementia Hospital Standards Annex C Page 5 of 41

6 4. Individualised and appropriate risk assessment will be undertaken and incorporated into the care plan involving relatives/carers in analysis. Minimum standard = 90%. Medical records check. Audit of policy or protocol governing interventions for patients displaying violent or challenging behaviours, aggression, agitation, suitable for people with dementia, including audit or prescribing of antipsychotics and sedatives. Safeguarding Adults Dementia Hospital Standards Annex C Page 6 of 41

7 Trust Dementia patient specific Care plans implemented Oct 2010 Patient with known Dementia, Patient with disorientation and Memory loss- risk assessment is part of the care plan Care plan guides staff to make appropriate referral to MHL team Nurse and Psychiatrist as part of team 7 days access to psychiatristnurse access 8am to 10pm 7 days a week Survey of Carer of patient with Dementia implemented Oct Trust Survey Volunteer targeting this group of carers to actively seek feedback on experience Carer listening event planned for Feb/March 2011 Implementation of the Living Well with Dementia Handbook and the This is me Document- Trust Group leading on this action Trust representation on County Antipsychotic Prescribing Guidelines Working Group-Protocol developed Audit undertaken 2010 as part of National Dementia Audit Trust Rapid Tranquilisation Policy updated 2010 to reflect best practice guidance Audit of care plan and referral to MHL team undertaken Dec 2010 for repeat March 2011 County agreed Antipsychotic prescribing guidelines to be available for staff via Trust Pharmacy Internet Audit field to be developed as part of annual Trust Dementia Audit Proforma Monitoring of prescribing by MHLT Monitoring of prescribing by Medical team Monitoring of prescribing by Pharmacy Team Training and Education Strategy Trust Violence and Aggression Policy update Trust Restraint Policy update Mental Health Liaison Team Operational Policy being updated ID MP SS/TF GB AS Safeguarding Adults Dementia Hospital Standards Annex C Page 7 of 41

8 LEVEL 2 1. Patient care is person centred informed by Dementia Care Mapping or similar methodology. Feedback from people trained in dementia care mapping. Dementia Care Mapping Training attended by two core members of Trust Dementia Working Group Enhanced audit as part of the National Dementias Audit March 2011( observational qualitative audit) Incorporate model for Person Centred Care into level 2 Dementia e- learning and level 3 safeguarding adult training Explore best option for implementation of Dementia Care Mapping approach within Acute Hospital setting Training and Education Strategy Dementia ward/dept Link training Strategy MA VR PH SS/TF 2. Ward champion role training programme is delivered. Evidence of attainment in training. Trust Dementia Working Group representatives Trust Safeguarding Adult Strategic Board Representatives Trust Matrons Trust Essence of Care Ward Link nurses Training and Education Strategy Dementia ward/dept Link training Strategy MA PH SS/TF 3. The trust Board regularly reviews serious and untoward incidents, falls, delayed discharges, and complaints associated with patients with a primary or secondary diagnosis of dementia. Evidence in governance mechanisms and records. Safeguarding Adults Dementia Hospital Standards Annex C Page 8 of 41

9 Board level reporting of all incidents and Lengths of stay - not sub divided by diagnosis at this time Dementia is a Mandatory Health Resource Group Code Confusion/ Disorientation are specific Health Resource Group codes Medical Team have responsibility to code clinical information to support clinical coding- clinical coding informs Trust Clinical Information Reporting Recording of clinical information relating to secondary and subsequent diagnosis codes at admission, during the episode of care and at discharge Explore options re data collection and reporting- establish an agreed system to inform Main Board Explore reporting options aligned to Trust Quality Committee Training and Education Strategy Strengthen Medical Team awareness of importance of correctly documenting clinical information to inform coding process MA ID ASt MD Safeguarding Adults Dementia Hospital Standards Annex C Page 9 of 41

10 Standard 2. Agreed assessment, admission and discharge processes with a needs specific care plan Standard 2: Agreed assessment, admission and discharge processes are in place, with care plans specific to meet the individual needs of people with dementia and their carer LEVEL 1 1. Prior to a planned admission or on an emergency admission, the lead relative/ carer/friend is identified if the patient has a diagnosis, or the patient has suspected cognitive impairment. They are provided with written information regarding the way in which they can support the patient with key names (consultant, lead ward nurse, liaison nurse / social worker). Minimum standard = 95% of lead relative / carer / friend receive information. Recording of actions taken followed by periodic review to include transfer of information about the lead carer between wards. Trust admission process identifies and documents lead carer/relative Trust Out Patient Project Pre admission assessment Triage screen question as part of Patient Fist IT system Patient Bedside Information folder Trust Carer Strategy Trust Carer Leaflet Survey and feedback on experience from Carers of patients with Dementia Explore options re best process to implement to achieve outcome indicators GB RM OPD Project JW Safeguarding Adults Dementia Hospital Standards Annex C Page 10 of 41

11 Standard 2. Agreed assessment, admission and discharge processes with a needs specific care plan 2. Prior to a planned admission This is me is completed if dementia has been diagnosed or the patient has suspected cognitive impairment. In an emergency admission an agreed modified version of This is me will be completed. This will inform an evidencebased multi-disciplinary care plan to be agreed within 24 hours with the patient and the main relative / carer / friend. Audit of pre-admission clinics use of This is me. Audit of acute admissions use of This is me. Implementation of use of this is me within prior to admission Country Dementia Programme Board action Implementation of the Living Well with Dementia Handbook and the This is me Document within GHT- Trust Group leading on this action Trust Dementia patient specific Care plans implemented Oct 2010 Patient with known Dementia, Patient with disorientation and Memory loss Embed Trust wide use of the Living Well with Dementia Handbook and the This is me Document Dementia ward/dept Link training Strategy Development of a modified this is me for E/Dept E/Dept admission information leaflet under development VR PH JW Pre-Assessment Team Safeguarding Adults Dementia Hospital Standards Annex C Page 11 of 41

12 Standard 2. Agreed assessment, admission and discharge processes with a needs specific care plan There is a system to detect and record cognitive impairment on the ward. All patients with suspected dementia receive a comprehensive assessment (unless there is evidence of this having been recently undertaken); where dementia is suspected but not yet diagnosed, this triggers a referral for assessment and differential diagnosis either in the hospital or in the community memory services. Minimum standard = 95%. Audit of elective and acute admission proformas and use of secondary flagging system e.g. a mini mental state examination. Audit evidence of seamless transition of information regarding patients to community memory services if not able to be assessed fully or diagnosed during hospital admission. Safeguarding Adults Dementia Hospital Standards Annex C Page 12 of 41

13 Standard 2. Agreed assessment, admission and discharge processes with a needs specific care plan Trust Dementia patient specific Care plans implemented Oct 2010 Patient with known Dementia, Patient with disorientation and Memory loss. - guides staff to make referral to Memory assessment Service at discharge and to MHL team during admission Use of the abbreviated Mental Test Score part of Trust Unscheduled care admission proforma documentation Reporting of discharge referrals to Memory Assessment Servicevia Infoflex IT system Monitoring of referrals and outcomes by Memory Assessment Service(2gether NHSFT) Work in progress to update nursing assessment documentation Gloucester patient Profile assessment questions for orientation/ comprehension Ensure clear process for documentation and develop reporting process for referral at the point of discharge Infoflex system ID 2getherNHSFT 3. Carers receive all relevant information about the patient s assessment and are involved in discussion about further assessment. Carers understand that an assessment of their own needs can be arranged. Minimum standard = 95%. Evidence of hospital guidelines and protocol on information sharing and involvement of carers/families. Audit. Safeguarding Adults Dementia Hospital Standards Annex C Page 13 of 41

14 Standard 2. Agreed assessment, admission and discharge processes with a needs specific care plan Trust admission process identifies and documents lead carer/relative Trust Out Patient Project Pre admission assessment Trust Carer Strategy Trust Carer Leaflet Updated Nursing admission assessment documentation includes section re Carers needs assessment Update of Trust Discharge documentation ID GB 4. There is an agreed system in place across the hospital so that staff are aware of the person s dementia (visual identifier or marker in notes). Minimum standard = 100%. Audit of compliance e.g. use of a coloured sticker or other prominent system obvious for all staff. Implementation of use of this is me within prior to admission County Dementia Programme Board action(dpmb) Implementation of the Living Well with Dementia Handbook and the This is me Document within GHT- Trust Group leading on this action Pre admission assessment Triage screen question as part of Patient Fist IT system Updated Nursing admission assessment documentation has section to document if the patient is known to have Dementia Development of PAS Plus IT System Explore proposal for a purple butterfly symbol as part of Pas Plus screen for patient with Dementia Proposal to implement a Trust Reasonable Adjustments Patient ID wristband being scoped - Aligned with Trust LD strategy. JW Pas Plus Project lead DPMB Safeguarding Adults Dementia Hospital Standards Annex C Page 14 of 41

15 Standard 2. Agreed assessment, admission and discharge processes with a needs specific care plan 4. Discharge is an actively managed process that begins within 24 hours of admission. Minimum standard = 95%. Audit of notes / care plan of this process. Trust Discharge Board Action Plan Annual Discharge audit Trust Discharge Policy Update of Trust Discharge documentation Development of Trust Dementia Audit Proforma MA Matrons Discharge Team 5. Information about discharge and support (written in plain English or other appropriate language) is made available to patients, relatives and carers on admission. Minimum standard = 95%. Audit in conjunction with Alzheimer s Society. Work in progress as part of Learning Disability Strategy Work in progress as part of Discharge Board Action Plan Trust Carer Strategy Trust Carer Leaflet Patient Bedside Information folder Trust Discharge Policy Ensure work progressing reflects needs of patient with dementia and their carers MA GB Discharge Team Safeguarding Adults Dementia Hospital Standards Annex C Page 15 of 41

16 Standard 2. Agreed assessment, admission and discharge processes with a needs specific care plan 6. There is a named person who takes responsibility for discharge coordination for people with dementia, who has been trained in the ongoing needs of people with dementia and has experience of working with people with dementia and their carers. Audit of care plans. Trust Discharge policy Trust training on Discharge policy Trust Discharge documentation Annual Trust Discharge Audit Programme Training and Education Strategy Dementia ward/dept Link training Strategy Development of Trust Dementia Audit Proforma Review Discharge Training content PH Discharge Team 7. Discharge plans clearly document the patient s cognitive and functional status, treatment plan and community support plan. This information is provided to carer/s. Minimum standard = 95%. Audit of discharge plans to include collaborative work with other agencies to agree community support plan. Infoflex summaries Trust Discharge Documentation Develop reporting via Infoflex Developments to Trust Discharge Documentation ID Safeguarding Adults Dementia Hospital Standards Annex C Page 16 of 41

17 Standard 2. Agreed assessment, admission and discharge processes with a needs specific care plan 8. The hospital has access to intermediate care services which will support people with dementia where required and be available to avoid delayed hospital discharge. Audit of referrals and outcomes. Intermediate Care Services referral criteria NHS Gloucestershire Single Point of access GHT patient pathway and under development County Dementia Programme Board action(dpmb) Integrated patient pathway primary Care, GHT and Community Hospitals ID MA DPMB Safeguarding Adults Dementia Hospital Standards Annex C Page 17 of 41

18 Standard 2. Agreed assessment, admission and discharge processes with a needs specific care plan LEVEL 2 1. Care pathways for patients with dementia, audit of patient notes and feedback from patient / carers have been reviewed at least annually, led by the senior clinical lead. Minimum standard = 100%. Evidence of updated care pathways. Evidence of action plan following audit of feedback. Trust Dementia patient specific Care plans implemented Oct 2010 Patient with known Dementia, Patient with disorientation and Memory loss. - guides staff to make referral to Memory assessment Service at discharge and to MHL team during admission GHT patient pathway and under development Audit undertaken 2010 as part of National Dementia Audit Audit of care plan and referral to MHL team undertaken Dec 2010 for repeat March 2011 Dementia Audit Proforma under development ID LD 2. Discharge coordinator training programme is delivered. Evidence of attainment in training. Trust Discharge policy Trust training on Discharge policy Trust Discharge documentation Annual Trust Discharge Audit Programme Training and Education Strategy Dementia ward/dept Link training Strategy Development of Trust Dementia Audit Proforma Review Discharge Training content Dementia Audit Proforma under development PH Discharge Team Safeguarding Adults Dementia Hospital Standards Annex C Page 18 of 41

19 Standard 2. Agreed assessment, admission and discharge processes with a needs specific care plan 3. The hospital has access to a range of intermediate care services. These services meet local assessed need and they demonstrate effective diversion from acute care and care homes. Audit of referrals and outcomes. Intermediate Care Services referral criteria monitoring of service delivery and outcomes by NHS Gloucestershire NHS Gloucestershire Single Point of access GHT patient pathway and under development County Dementia Programme Board action(dpmb) Integrated patient pathway primary Care, GHT and Community Hospitals DPMB ID Safeguarding Adults Dementia Hospital Standards Annex C Page 19 of 41

20 Standard 3. Access to a specialist older people s mental health liaison service Standard 3: People with dementia or suspected cognitive impairment who are admitted to hospital, and their carers/families have access to a specialist mental health liaison service LEVEL 1 1. The hospital provides access to a specialist mental health liaison service, which provides expertise in dementia when required for advice, assessment, diagnosis, education and training throughout the hospital. Local commissioning arrangements assess need and determine activity levels for and outcomes delivered by the liaison service. NICE quality guidelines. Proportion of people with suspected or known dementia using acute and general hospital facilities that are assessed by the liaison service. Mental Health Liaison Team(MHLT)- Mental Health Nurse Team provide service 8am -10 pm 7day a week. Consultant Psychiatry access 7 days a week as part of core Mental Health Liaison Team Update MHLT operational policy to include reporting on outcomes and referrals TF 2. People with dementia who develop noncognitive symptoms that cause distress, or who develop behaviour that challenges are considered for referral to the liaison service for further assessment. Audit of % referred against % assessments. Need to consider number of people with dementia and what proportion might need specialist assessment (and why). Safeguarding Adults Dementia Hospital Standards Annex C Page 20 of 41

21 Standard 3. Access to a specialist older people s mental health liaison service Mental Health Liaison Team (MHLT)- Mental Health Nurse Team provide service 8am -10 pm 7day week. Consultant Psychiatry access 7 days a week as part of core Mental Health Liaison Team Update MHLT operational policy to include reporting on outcomes and referrals Mental Health Liaison Team Performance and Activity Reports data collection and reporting- establish an agreed system to support reporting and to inform Main Board TF MA MD ID Safeguarding Adults Dementia Hospital Standards Annex C Page 21 of 41

22 Standard 3. Access to a specialist older people s mental health liaison service LEVEL 2 1. There is agreement about how and when a full multi-disciplinary liaison service is in place for the local general and community hospitals. This includes the provision of consultant psychiatrist time, and the required capacity to meet the needs of patients with dementia in general and community hospital settings. This provision has been based on assessed need. Appropriate response-to-referrals are maintained within agreed timeframes. Annual audit of service. Mental Health Liaison Team(MHLT)- Mental Health Nurse Team provide service 8am -10 pm 7day. Consultant Psychiatry access 7 days a week as part of core Mental Health Liaison Team Update MHLT operational policy to include reporting on outcomes and referrals Mental Health Liaison Team Performance and Activity Reports data collection and reporting- establish an agreed system to support reporting and to inform Main Board TF MA ID 2. The role of liaison teams in their provision of regular training, for healthcare professionals in the hospital who provide care for people with dementia, should be incorporated in local training strategies (cross referenced to standard 8). Evidence of local agreement. Evidence within local training strategies. Safeguarding Adults Dementia Hospital Standards Annex C Page 22 of 41

23 Standard 3. Access to a specialist older people s mental health liaison service Update MHLT operational policy to include reporting on outcomes and referrals Mental Health Liaison Team Performance and Activity Reports Training and Education Strategy Dementia ward/dept Link training Strategy Staff Training Records PH TF Safeguarding Adults Dementia Hospital Standards Annex C Page 23 of 41

24 Standard 4. A dementia friendly hospital environment; minimising moves Standard 4: The hospital and ward environment is dementia-friendly, minimising the number of ward and unit moves within the hospital setting and between hospitals LEVEL 1 1. Clinical champion determines the signage requirements of wards to assist people with dementia. Signage is installed. Ward audit using tools from National Dementia Audit. Trust Patient Environment and Access Team Reports Trust Patient Environment and Access Group Trust Equality and Diversity Group and Action Plan Sub group to be established Training and Education Strategy Dementia ward/dept Link training Strategy Development of Trust Dementia Audit Proforma ID VR TF CM PH 2. A good sensory environment is maintained with lighting free of shadows or glare; patients are able to see a clock from their bed area; availability of calendars. Ward check. Clocks in bays and side rooms Trust Estates Team annual programme Trust Patient Environment and Access Team Reports Trust Patient Environment and Access Group Sub group to be established with action plan Training and Education Strategy Dementia ward/dept Link training Strategy Development of Trust Dementia Observational Audit Proforma Monitoring by Ward Band 7 and Matron ID VR TF CM PH Matrons Safeguarding Adults Dementia Hospital Standards Annex C Page 24 of 41

25 Standard 4. A dementia friendly hospital environment; minimising moves 3. Hospital policy endorses the principle that patients known to have dementia should not be moved between wards unless required for their care and treatment. Appropriate expertise should be brought to the patient rather than the patient be required to move. Clinical champion audits moves via patient notes. Trust Safeguarding Adult Strategy Trust Inpatient Transfer Policy Review and update Trust In-Patient Transfer Policy Sub group to be established with action plan Training and Education Strategy Dementia ward/dept Link training Strategy Monitoring of in-patient moves for this patient group develop compliance monitoring tool and reporting Development of PAS Plus IT System Explore proposal for a purple butterfly symbol as part of Pas Plus screen for patient with Dementia Proposal to implement a Trust Reasonable Adjustments Patient ID wristband being scoped - Aligned with Trust LD strategy. BMT PH JW Pas Plus Project lead DPMB Safeguarding Adults Dementia Hospital Standards Annex C Page 25 of 41

26 Standard 4. A dementia friendly hospital environment; minimising moves 4. Patients should not be moved between wards between 8pm-8am. Moves at mealtimes and medication times are also avoided. Discussion regarding a required move takes place with the patient. Carers/families should be given adequate notice of a proposed move and asked if they wish to assist in the transfer. Clinical champion audits moves via patient notes. Trust Safeguarding Adult Strategy Trust Inpatient Transfer Policy Trust Carers Policy and Strategy Review and update Trust In-Patient Transfer Policy Sub group to be established with action plan Training and Education Strategy Dementia ward/dept Link training Strategy Monitoring of in-patient moves for this patient group develop compliance monitoring tool and reporting BMT PH Safeguarding Adults Dementia Hospital Standards Annex C Page 26 of 41

27 Standard 4. A dementia friendly hospital environment; minimising moves 5. If a move is unavoidable the completed personal profile/wishes This is me, preferences and beliefs should be transferred to new ward along with all medical/care notes. Key personnel identify themselves and implement full orientation policy. Clinical champion audits moves via patient notes. Trust Safeguarding Adult Strategy Trust Inpatient Transfer Policy Trust Dementia patient specific Care plans implemented Oct 2010 Patient with known Dementia, Patient with disorientation and Memory loss Review and update Trust In-Patient Transfer Policy Training and Education Strategy Dementia ward/dept Link training Strategy Monitoring of in-patient moves for this patient group develop compliance monitoring tool and reporting Refer to Standard 2.2 actions BMT PH VR Safeguarding Adults Dementia Hospital Standards Annex C Page 27 of 41

28 Standard 4. A dementia friendly hospital environment; minimising moves LEVEL 2 1. All key communal areas within hospital used by people with dementia to be identified, and clinical champion agrees appropriate adjustments to environment (signage, easy to interpret menus and daily routines, coloured privacy doors). Engagement and agreed periodic review by clinical champion with facilities management, in partnership with Alzheimer s Society. Trust Estates Team annual programme Trust Patient Environment and Access Team Reports Trust Patient Environment and Access Group (PEAG) Picture menus under development Trust Patient Information Policy Sub group to be established with action plan Training and Education Strategy Dementia ward/dept Link training Strategy Development of Trust Dementia Observational Audit Proforma Monitoring by Ward Band 7senior nurses and Matrons Review of Discharge Waiting Lounge Policy and Environment ID MA VR TF CM PH GB 2. Daily therapeutic and recreational sessions or activities are available. Wards may include activities such as art therapy, music, gentle hand massage, activity boxes If discreet space is not available then activities are brought to the patient. Ward review as part of audit. Patient Care and Treatment plans reflecting involvement and of Multi- Professional Team Arts in Trust projects Carers Strategy Reminiscence boxes to be explored Sub group to be established with action plan Review of Trust Volunteer Strategy Development of Trust Dementia Observational Audit Proforma VR SA TF GB Safeguarding Adults Dementia Hospital Standards Annex C Page 28 of 41

29 Standard 4. A dementia friendly hospital environment; minimising moves 3. Periodic review of impact on ward environment during periods of high / peak activity. Ward review as part of audit. Monitoring by Band 7 senior Nurse Matron Monitoring Development of Trust Dementia Observational Audit Proforma MA Band 7 Senior Nurses Matrons Safeguarding Adults Dementia Hospital Standards Annex C Page 29 of 41

30 Standard 5. Nutrition and hydration needs are well met Standard 5: The nutrition and hydration needs of people with dementia are well met LEVEL 1 1. All patients will have a weight assessment on admission, at weekly intervals, and near to discharge (for inclusion in discharge summary). Minimum standard = 95% (exceptions: terminal illness, day cases, short elective, or impossible to weigh clinically). Nursing records. Trust Nutrition and Hydration Action Plan and audit programme 2011/2012 Trust Nutrition and Hydration Action Plan and audit programme to be reviewed and amended Development of Trust Dementia Audit Proforma AS LD Band 7 Senior Nurses Matrons 2. All patients will be assessed using the MUST tool or standard malnutrition universal screening tool. Minimum standard = 95%. Nursing records. Trust Nutrition and Hydration Action Plan and audit programme 2011/2012 Trust Nutrition and Hydration Action Plan and audit programme to be reviewed and amended Development of Trust Dementia Audit Proforma AS LD Band 7 Senior Nurses Matrons Safeguarding Adults Dementia Hospital Standards Annex C Page 30 of 41

31 Standard 5. Nutrition and hydration needs are well met 3. Individual tastes, habits and eating preferences are identified and recorded in This is me as part of the initial assessment in conjunction with carers. Minimum standard = 95%. Nursing records. Trust Dementia patient specific Care plans implemented Oct 2010 Patient with known Dementia, Patient with disorientation and Memory loss Trust Nutrition Care Planning Development of Trust Dementia Audit Proforma Refer to actions for Standard 2.2 LD Band 7 Senior Nurses Matrons 4. Protected mealtimes; volunteers, carers, friends actively encouraged to assist; patients sitting at a table more socially if they are able to, and wish to. Lunchtime review as part of audit. Trust Nutrition and Hydration Action Plan and audit programme 2011/2012 Carers Leaflet Carers Strategy Volunteer Strategy Trust Nutrition and Hydration Action Plan and audit programme to be reviewed and amended Development of Trust Dementia Observational Audit Proforma AS LD GB Band 7 Senior Nurses Matrons Safeguarding Adults Dementia Hospital Standards Annex C Page 31 of 41

32 Standard 5. Nutrition and hydration needs are well met 5. Flexibility in provision and timing of food and in the presentation of food e.g. snacks and finger foods offered if necessary; recognising some patients may take a long time to eat a meal. Inspection. Trust Nutrition and Hydration Action Plan and audit programme 2011/2012 Trust Dementia patient specific Care plans implemented Oct 2010 Patient with known Dementia, Patient with disorientation and Memory loss Trust Nutrition Care Planning Trust Nutrition and Hydration Action Plan and audit programme to be reviewed and amended Development of Trust Dementia Audit Proforma AS LD Band 7 Senior Nurses Matrons 6. Coloured trays, utensils, crockery are used to support patients with dementia at mealtimes. Inspection. Trust Nutrition and Hydration Action Plan and audit programme 2011/2012 Trust Dementia patient specific Care plans implemented Oct 2010 Patient with known Dementia, Patient with disorientation and Memory loss Trust Nutrition Care Planning Patient Care and Treatment plans reflecting involvement and of Multi- Professional Team Red Tray system implemented as part of Essence of Care Strategy and Trust Hungry to be Heard Action Plan Trust Nutrition and Hydration Action Plan and audit programme to be reviewed and amended Development of Trust Dementia Audit Proforma AS LD Band 7 Senior Nurses Matrons Safeguarding Adults Dementia Hospital Standards Annex C Page 32 of 41

33 Standard 5. Nutrition and hydration needs are well met LEVEL 2 1. There is access within 12 hours to specialist assessment for and advice on helping patients with dementia in their swallowing and eating, with information provided to carers/families. Audit of referrals and responses. Trust Nutrition and Hydration Action Plan and audit programme 2011/2012 Trust Dementia patient specific Care plans implemented Oct 2010 Patient with known Dementia, Patient with disorientation and Memory loss Trust Nutrition Care Planning Patient Care and Treatment plans reflecting involvement and of Multi- Professional Team Trust Nutrition and Hydration Action Plan and audit programme to be reviewed and amended Operational policy and monitoring of referrals and outcomes by Dietitian and Speech and Language Therapy Senior Lead Development of Trust Dementia Audit Proforma AS ID Trust Lead for Dietetics Trust Speech and Language Therapy Lead LD Safeguarding Adults Dementia Hospital Standards Annex C Page 33 of 41

34 Standard 6. Promoting the contribution of volunteers Standard 6: The hospital and wards promote the contribution of volunteers to the well-being of people with dementia in hospital LEVEL 1 1. There is a lead person with senior clinical lead responsibility within the hospital for defining the role and ensuring coordination and support of volunteers who promote wellbeing of people with dementia in the hospital. Identification of lead person, and agreed job description. Trust Volunteer Strategy Trust Essence of Care Strategy Trust Dementia Working Group Action Plan Review and update Trust Essence of Care Strategy MA GB 2. Opportunities for enhancing the patient experience (mealtimes; social activities) are identified by ward champion with the appointed volunteer coordinator. Incorporated into ward champion role (see standard 1). Trust Volunteer Strategy Trust Essence of Care Strategy Trust Dementia Working Group Action Plan Review and update Trust Essence of Care Strategy Refer to actions for Standard 4 and Standard 5 MA GB 3. Processes agreed between volunteer coordinator and ward champion about the direction, support and feedback provided to volunteers and carers. Coordinator has agreed process for review with volunteers. Safeguarding Adults Dementia Hospital Standards Annex C Page 34 of 41

35 Standard 6. Promoting the contribution of volunteers Trust Volunteer Strategy Trust Essence of Care Strategy Trust Dementia Working Group Action Plan Review and update Trust Essence of Care Strategy Refer to actions for Standard 4 and Standard 5 MA GB Safeguarding Adults Dementia Hospital Standards Annex C Page 35 of 41

36 Standard 6. Promoting the contribution of volunteers LEVEL 2 1. A regular review is undertaken about the opportunities for involving volunteers and plans for recruitment and retention to meet needs, which are agreed with the clinical champion. Review of audit. Trust Volunteer Strategy Trust Essence of Care Strategy Carers Survey Strategy and results Review and update Trust Volunteers Strategy Refer to actions for Standard 4 and Standard 5 Trust Dementia Audit Observational Proforma MA GB 2. A range of training opportunities are offered at agreed periods for new and existing volunteers. Evidence of training within the personal records of volunteers. Trust Volunteer Strategy Trust Essence of Care Strategy Volunteer Training Programme and records of attendance Review and update Trust Volunteers Strategy and Training programme Trust Dementia Training and Education Strategy Refer to actions for Standard 4 and Standard 5 MA GB PH Safeguarding Adults Dementia Hospital Standards Annex C Page 36 of 41

37 Standard 7. Ensure quality of care at the end of life Standard 7: The hospital and wards ensure quality of care at the end of life LEVEL 1 1. Patients with dementia identified as approaching their end of life are flagged to General Practitioners for entry onto end of life care register and taking appropriate action. Proportion of patients whose key worker received and recorded end of life plan. Trust End of Life Strategy Trust Dementia Working Group Action Plan Dementia Programme Managers Board(DPMB) Review and update Trust end of life Strategy Review Trust Dementia Working Group Action Plan Explore options to achieve this outcome link with DPMB JB ID VR TF LM 2. All patients with dementia who will remain in hospital to die are cared for using the Liverpool Care Pathway or agreed integrated care pathway for care of dying. Audit. Trust End of Life Strategy and audit programme Trust Dementia Working Group Action Plan Trust Training and Education Strategy Review and update Trust end of life Strategy Review Trust Dementia Working Group Action Plan Development of Trust Dementia Audit Proforma JB ID LM Safeguarding Adults Dementia Hospital Standards Annex C Page 37 of 41

38 Standard 7. Ensure quality of care at the end of life LEVEL 2 1. All clinical and support staff working with people with dementia requiring end of life care have received appropriate training. Minimum standard =100%. Audit of recorded on personnel records against required competences. Trust End of Life Strategy and Training and Education Strategy Trust Dementia Working Group Action Plan and Trust Training and Education Strategy Review and update Trust end of life Strategy and Training Strategy Trust Dementia Working Group Action Plan and Trust Training and Education Strategy JB PH VR TF Safeguarding Adults Dementia Hospital Standards Annex C Page 38 of 41

39 Standard 8: Appropriate training and workforce development are in place to promote and enhance the care of people with dementia in general and community hospitals, and their carers/families LEVEL 1 1. All new staff receive mandatory induction in caring for people with dementia based on South West standards and required competences. Recorded in personnel records against required competences. Trust Dementia Working Group Action Plan and Trust Training and Education Strategy Level 1 e-learning approaching live launch Trust Dementia Working Group Action Plan and Trust Training and Education Strategy MA PH Safeguarding Adults Dementia Hospital Standards Annex C Page 39 of 41

40 2. There is a training and knowledge framework in place and a strategy for implementation agreed. The framework identifies necessary Evidence of progress in delivering reflective and person-centred practitioners. skill development in working with and caring for people with dementia and utilises the specialist mental health liaison service within the hospital, including: communication skills, and working with older people with sensory impairment; addressing behaviours that challenge; assessing capacity, and the Mental Capacity Act; and the protection of vulnerable adults. Trust Dementia Training and Education Strategy Trust Mental Capacity Act Mandatory Training Trust Safeguarding Adult Level 1,2 and 3 Training MHLT ward training sessions Dementia Resource Pack on Trust staff intranet Dementia webpage GHT senior representative on County Training and Education Strategy Committee Incorporate above themes and model for Person Centred Care into level 2 Dementia e-learning and level 3 safeguarding adult training Update Training and Education Strategy Dementia ward/dept Link training Strategy Staff Training Records Development of Trust Dementia Audit Proforma Development of Trust Dementia Audit Observational Proforma PH ID VR TF LD Safeguarding Adults Dementia Hospital Standards Annex C Page 40 of 41

41 LEVEL 2 1. The training and knowledge framework is implemented. Evidenced by annual review of implementation. Trust Dementia Training and Education Strategy Trust Mental Capacity Act Mandatory Training Trust Safeguarding Adult Level 1,2 and 3 Training GHT senior representative on County Training and Education Strategy Committee Update Training and Education Strategy Dementia ward/dept Link training Strategy Development of Trust Dementia Audit Proforma Development of Trust Dementia Audit Observational Proforma Staff Training Records PH Safeguarding Adults Dementia Hospital Standards Annex C Page 41 of 41