SERVICE FRAMEWORK FOR OLDER PEOPLE

SERVICE FRAMEWORK FOR OLDER PEOPLE

TABLE of CONTENTS SECTION STANDARD TITLE Page No Foreword 4 Summary of Standards 6 1 Introduction to Service Frameworks 36 2 The Service Framework for Older People 42 3 PERSON CENTRED CARE 52 1 Engagement and Choice 54 2 Equality of Opportunity and Eliminating 58 Discrimination 3 Communication (Generic) 61 4 Involvement (Generic) 63 5 Advocacy 66 6 Independent Advocacy (Generic) 69 4 HEALTH AND SOCIAL WELLBEING 73 IMPROVEMENT 7 Healthy Ageing 75 8 Nutrition in Older People 80 9 Healthy Eating (Generic) 86 10 Smoking (Generic) 88 11 Alcohol (Generic) 91 12 Activity (Generic) 93 13 Prevention of Falls 95 14 Social Inclusion and Quality of Life 100 5 SAFEGUARDING 106 15 Raising Public Awareness 107 16 Accessing Services to Safeguard 110 Older People 17 Responding to Older People who are at Risk 114 18 Development of Protection Plans 118 19 Safeguarding People (Generic) 122 6 CARERS 128 20 Identifying and Supporting Carers (Generic) 130 21 Identification and Recognition of Carers 135 22 Information for Carers 138 23 Financial Advice and Information for Carers 141 24 Flexible, Responsive Services 144 25 Respite for Carers 148 26 Carer Health and Well-Being 151 1

27 Involving Carers 155 7 CONDITIONS MORE COMMON IN OLDER 158 PEOPLE 28 Falls Screening in Primary Care 160 29 Falls Presenting to Intermediate or Secondary 164 Care 30 Hospital Care of Older People with a 168 Fracture 31 Continence Services for Older People 171 32 Recognition and Prevention of 175 Delirium 33 Management of Delirium 179 34 End of Life Care Planning for Older People with 182 Advanced Dementia 35 Immobility 185 8 MEDICINES MANAGEMENT 189 36 Medicines Management 190 37 Medicines Review 194 9 TRANSITIONS OF CARE 198 38 Single Access Point for Information and 200 Services. 39 Re-ablement to Maintain Independence 203 40 Early Identification to Maximise 206 Independence 41 Increased Awareness of Needs in General 210 Hospitals 42 Improved Access to Assessment and 214 Rehabilitation 43 Specialist Support in Nursing Homes 217 44 Person-centred Palliative and End of Life 220 Care 45 Palliative and End of Life Care (Generic) 224 46 Improved Dementia and Mental Health Services 228 2

Annex A List of Service Frameworks 232 Annex B Glossary of Terms Used 233 Annex C Abbreviations 239 Annex D Project Team 240 Annex E Membership of Older People s Reference Group 242 Annex F Membership of Sub Groups 243 Annex G Comments and Recommendations from the Older 250 Peoples Reference Group Annex H Summary of the Report of the Older Peoples Service 252 Framework Reference Group Annex I Legislative and Policy Context 257 3

Foreword As Minister for Health, Social Services and Public Safety I am determined to ensure that services are safe, improve health and wellbeing of individuals and communities and, at the same time, make the best use of available resources. In addition, I believe it is important that services, as far as possible, meet the needs and preferences of people and are accessible to all regardless of where they live or who they are. To make this happen, my Department has started work on the development of a set of Service Frameworks which set out explicit standards for health and social care to be used by patients, clients, carers and their wider families to help them understand the standard of care they can expect to receive. These Frameworks will also be used by health and social care organisations in planning and delivering services. The first group of Frameworks focus on the most significant causes of ill health and disability in Northern Ireland cardiovascular disease, respiratory disease, cancer, mental health and learning disability. In addition to the Service Framework for Older People, work has also commenced to develop a Service Framework for Children and Young People. The Service Framework for Older People sets standards in relation to people over 65 whilst taking account of the needs of those over 50, where appropriate, particularly in relation to preventative measures. The standards relate to Person-centred Care; Health and Social Wellbeing Improvement; Safeguarding; Carers; Conditions more Common in Older People; Medicines Management and Transitions of Care. Each standard is supported by levels of performance to be achieved over 3 years and the Framework will be subject to regular review and refinement in the light of new evidence. This will ensure that it provides a sound basis for continued improvement in the quality of health and social services. The development of this Framework has been an inclusive process involving people from all aspects of health and social care, patients, clients and carers, all of whose support has been invaluable. 4

The application of the standards set out in this Framework has the potential to transform the quality of service provision for older people. Edwin Poots MLA Minister for Health, Social Services and Public Safety 5

SUMMARY of STANDARDS PERSON CENTRED CARE STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 1: All older people should be treated as individuals, be enabled to engage fully in making informed choices about their own care / treatment and have control over the way in which it is delivered. Standard 2: All older people should expect the same opportunity of access to assessment, care and treatment as other users of health and social care services. 1. Trusts will have a Person-centred Care Module as part of Corporate Induction Training. 2. Assessment of need and care planning is developed collaboratively between staff and older people on a multi-disciplinary basis. 3. Older people receive support / services to meet their individual needs at the right time. 1.Older people experience equal access to assessment, care and treatment. 2. Review of Trusts Equality Policies that safeguard and promote Human Rights. All Trusts. March 2015 (end of Year 1) Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline March 2015 (end of Year 1) Performance level set once baseline is established. All Trusts March 2015 (end of Year 1) 6

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 3 (Generic): All patients, clients, carers and the public should be engaged through effective communications by all organisations delivering health and social care. 1. Percentage of patients and clients expressing satisfaction with communication Establish baseline and set target March 2014 Report percentage increase of patient and client satisfaction with communication March 2015 Report percentage increase of patient and client satisfaction with communication March 2016 Standard 4 (Generic): All patients, clients, carers and the public should have opportunities to be actively involved in the planning, delivery and monitoring of health and social care at all levels. 1. Percentage of job descriptions containing PPI as responsibility Year 1: senior and middle management Year 2: designated PPI leads at all levels of HSC organisations Year 3: all new job descriptions Establish baseline and set target March 2014 Monitor progress March 2015 100% - in all new job descriptions March 2016 2.Percentage of patients and clients expressing satisfaction Establish baseline and set target March 2014 Report percentage increase of patient and client satisfaction March 2015 Report percentage increase of patient and client satisfaction March 2016 7

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 4:(continued) 3.Percentage of staff who have gained PPI training (details to be agreed for 2014/2015) Conduct training needs assessment for PPI, commission design of PPI training programme (March 2014) Establish baseline and set target March 2015. Standard 5: All older people should have access to independent advocacy that provides information, advice and support to enable them to make informed choices and be fully involved in decisions affecting them. 1. Each Trust has at least one Service Level Agreement with the voluntary or community sector to provide information, advice and advocacy services. 2. Increased awareness among older people of the role and function of advocacy. Monitor percentage of staff trained at different levels in PPI March 2016 All Trusts. March 2015 (end of Year 1) Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Standard 6 (Generic): Users of health and social care services and their carers should have access to independent advocacy as required. 1. To be determined. To be determined 8

HEALTH AND SOCIAL WELL BEING IMPROVEMENT STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 7: All older people should have access to evidence based health and wellbeing advice, information, programmes and services that are tailored to address their specific and varied health and wellbeing needs across their life course. 1. Board and PHA review of current services for older people to ensure that their health and wellbeing needs are identified and inform service change. 2. Trusts review of their coordination of the development and delivery of multifaceted health and wellbeing programmes and services to address the wider health and wellbeing needs of older people. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. Standard 8: All older people should be supported to achieve optimum nutritional health and to maintain a healthy body weight. 3. Trusts detailing the provision of appropriate assessment, advice and information on all aspects of health and wellbeing. Mechanisms should be in place to effectively signpost/refer older people to multi sectoral services and support. 1. The Board/PHA s review of the current services addressing the nutritional needs of older people and ensure interventions are in place to promote healthy eating and identify and address individuals at risk of malnutrition. 60% March 2015 (end of Year 1) 75% March 2016 (end of Year 2) 90% March 2017 (end of Year 3) Establish baseline. March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. 9

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 8: (continued) 2. Trusts reports showing that older people within their care have access to and are adequately supported to maintain a healthy and well balanced diet. All Trusts March 2015 (end of Year 1) and ongoing. Standard 9 (Generic): All HSC staff, as appropriate, should provide people with healthy eating support and guidance according to their needs. 3. Number of older people and, where appropriate their carers have access to a comprehensive range of health information, advice and support services/ programmes to maintain and improve their nutritional and oral health. 4. Number of older people in acute, residential or nursing homes, or in receipt of a community care package who have access to oral health screening and appropriate dental treatment and care. 1. Percentage of people eating the recommended 5 portions of fruit or vegetables each day. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. Baseline for 2011/12 = 32% overall, 26% for males and 36% for females Target: maintain or at best increase percentage by 1% year on year 10

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 10 (Generic): All HSC staff, as appropriate, should advise people who smoke of the risks associated with smoking and signpost them to well-developed specialist smoking cessation services. 1. Number of people who are accessing Stop Smoking Services 2. Proportion of the smoking population who are accessing Stop Smoking Services. Baseline 2011/12 = 39204. - 4 % year on year increase (March 2014-16) Baseline 2011/12 =10.8%. NICE guidance and the ten year tobacco strategy call for a target of over 5% of the smoking population to be reached, hence target to maintain at >/= 5% (March 2014-16) 3. Number of people using stop smoking services who have quit at 4 weeks and 52 weeks. Baseline 2011/12 = 20,299 for those quit at 4 weeks and 5,889 for those quit at 52 weeks. Target 4% increase in respective numbers year on year. (March 2014-16) Standard 11 (Generic): All HSC staff, as appropriate, should provide support and advice on recommended levels of alcohol consumption. 1. Percentage of people who receive screening in primary care settings in relation to their alcohol consumption. Establish baseline March 2014 Performance level to be determined once baseline established March 2015 11

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 12 (Generic): All HSC staff, as appropriate, should provide support and advice on recommended levels of physical activity. 1. Percentage of people meeting the recommended level of physical activity per week. New physical activity guidelines were launched in 2011 and as such a new suite of questions to establish the percentage of people of people meeting the recommended level of physical activity per week has been integrated within the 2012/13 Northern Ireland Health Survey. It is anticipated these new baseline results will be available in Nov / Dec 2013. March 2014 Performance level to be agreed thereafter Standard 13: Older people should be informed of the factors which increase risk of fragility fractures as a result of osteoporosis or reduced bone strength. and be able to access interventions to reduce the risk. 1. Health and Social Care Board s/public Health Agency s review of the current provision of falls prevention services to ensure the provision of comprehensive, evidence based falls prevention services for all older people. 2.Trust Report detailing the provision of coordinated Falls Services that increase awareness of the ways to prevent and reduce the risk of falling, provide falls prevention programmes that have reduced the risk of older people falling, including strength and balance training and offer services to reduce the impact of falls. All Trusts March 2015 (end of Year 1) and ongoing. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. 12

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 13: (continued) 3.Trusts will ensure the provision of coordinated, community based health and wellbeing services and programmes that seek to reduce the risk of falling by increasing physical activity, maintaining a healthy diet, ensuring regular vision checks, stopping smoking, reducing alcohol intake, maintaining safe homes and neighbourhood environments. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. 4. Older people in contact with health and social care services are routinely asked whether they have fallen in the past year, have their risk of falling assessed and provided with appropriate advice, support and signposting to services to address their specific needs. 5. All nursing homes that have been contracted by Health and Social Care Trusts will have in place actions to reduce the risk and impact of falling by residents. 60% March 2015 (end of Year 1) 75% March 2016 (end of Year 2) 90% March 2017(end of Year 3) Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. 6. All older people, who have a fall and call for an ambulance, are placed on an appropriate pathway for assessment and intervention. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. 13

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 14: All older people will be supported to maintain their mental health and wellbeing, quality of life and independence as they grow older. 1. Health and Social Care Board s/public Health Agency s review of the current provision of services to address the mental health and social wellbeing needs of older people and ensure effective multi-sectoral approaches are developed and maintained to address the wider social determinants and impact of social isolation. All Trusts. March 2015 (end of Year 1) and ongoing. 2. Health and Social Care Trusts coordination, development and delivery of multifaceted services and programmes with local partners to address the wider mental health and social wellbeing needs of older people and their carers. 3. All older people in contact with services have access to appropriate assessment of their wider health and well-being needs and signposting to further help and support as required. All Trusts. March 2015 (end of Year 1) and ongoing. 60% March 2015 (end of Year 1) 75% March 2016 (end of Year 2) 100% March 2017 (end of Year 3) 14

SAFEGUARDING STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 15: Health and social care organisations must work together to prevent the abuse or exploitation of older people by raising public awareness and developing a clear message that such abuse is unacceptable and will not be tolerated. 1. Northern Ireland Adult Safeguarding Partnership s (NIASP) Strategic Plan and Annual Action Plans to include a prevention plan. 2. Local Adult Safeguarding Partnerships (LASPs) Safeguarding Plan and annual Action Plans to include a local prevention plan. 3. Delivery of at least one Peer Educator training programme for older people in each Trust area. All Trusts. March 2015 (end of Year 1) and ongoing. All Trusts. March 2015 (end of Year 1) and ongoing. All Trusts. March 2016 (end of Year 2) and ongoing Standard 16: Health and social care professionals should work with older people, their carers and relevant others to recognise situations of abuse, or exploitation and to access services to safeguard vulnerable people. 1. NIASP Strategy and associated Annual Action Plans will include the development, implementation and review of standardised regional thresholds for access to adult safeguarding services to improve consistency of screening and decision making. 2. Each LASP Safeguarding Plan and associated annual Action Plans will include clear signposting of services and standardised regional thresholds for access to adults safeguarding services, All Trusts. March 2015 (end of Year 1) and ongoing All Trusts March 2015 (end of Year 1) and ongoing 15

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 16: (continued) improve consistency of screening and decision making. 3. Each provider organisation ensures that information on how to access safeguarding services is available to service users and their carers. 4. Each provider organisation ensures that all staff members receive appropriate training on how to recognise abuse and access safeguarding services. 5. Establishment of at least one Peer Advocacy service to support people through the process of disclosure of abuse, exploitation, or neglect in each Trust area. 6. Number of service users where potential abuse is identified at initial assessment as % of referrals to safeguarding services. 80% March 2015 (end of Year 1) and ongoing 80% March 2015 (end of Year 1) and ongoing All Trusts. March 2016 (end of Year 2) and ongoing Establish baseline. March 2016 (end of Year 2) and ongoing Performance level set once baseline is established. 16

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 17: Health and social care organisations that receive a report that an individual has been, or may be experiencing abuse or neglect will respond in a positive, timely and proactive manner. 1. NIASP will ensure that all regional adult safeguarding procedures include timescales for responding to allegations of abuse. 2. Local Adult Safeguarding Plans will ensure local safeguarding services comply with timescales for responding to allegations of abuse. All Trusts. March 2015 (end of Year 1) and ongoing Establish baseline. March 2016 (end of Year 2) and ongoing Performance level set once baseline is established. Standard 18: Health and social care organisations will work in partnership with service users, their carers and/or representatives and other relevant agencies so that any Protection Plan is tailored to meet the needs of the older person. 3. Service users are enabled to exercise choice and control whenever possible in relation to the management of allegations of abuse. 4. Percentage of older people who have not had a NISAT specialist risk assessment completed which includes a specialist safeguarding assessment is required. 1. NIASP will establish an Adult Safeguarding Forum, which will ensure that users of safeguarding services contribute to the design and commissioning of safeguarding services. 2. Number of people and/or their advocates, who have their need for safeguarding met through their participation in processes such as care Establish baseline. March 2016 (end of Year 2) and ongoing. Performance level set once baseline is established. Establish baseline. March 2016 (end of Year 2) and ongoing Performance level set once baseline is established. 100% March 2016 (end of Year 2) and ongoing Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is 17

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 18: (continued) planning, protection planning, case conferences, family group conferences. established. Standard 19 (Generic): All HSC staff should ensure that people of all ages are safeguarded from harm through abuse, exploitation or neglect. 3. Number of Protection Plans in place as a percentage of referrals accepted by Safeguarding Services. 1. All HSC organisations and organisations providing services on behalf of the HSC have a Safeguarding Policy in place, which is effectively aligned with other organisational policies (e.g. recruitment, governance, complaints, SAIs, training, supervision, etc.) The Safeguarding Policy is supported by robust procedures and guidelines. 2. All HSC organisations and organisations providing services on behalf of the HSC have Safeguarding Plans in place. 3. All HSC organisations and organisations providing services on behalf of the HSC have Safeguarding champions in place in order to promote awareness of safeguarding issues in their workplace. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. Establish baseline - March 2014 Performance level to be determined once baseline established Establish baseline - March 2014 Performance level to be determined once baseline established Establish baseline - March 2014 Performance level to be determined once baseline established 18

CARERS STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 20 (Generic): All HSC staff should identify carers (whether they are parents, family members, siblings or friends) at the earliest opportunity to work in partnership with them and to ensure that they have effective support as needed. 1. Number of front line staff in a range of settings participating in Carer Awareness Training Programmes 2a. The number of carers who are offered Carers Assessments 2b. The percentage of carers who participate in Carers Assessments 20% March 2015 50% March 2016 Improvement targets set by HSCB in conjunction with Carers Strategy Implementation Group. Reviewed annually Improvement targets set by HSCB in conjunction with Carers Strategy Implementation Group. Reviewed annually Standard 21: Older carers and carers of older people should be identified at the earliest opportunity, by all staff in relevant organisations working together, to improve awareness and recognition of the carer s role in a range of settings. 1a. The number of carers who are identified by GP practices. 1b. The percentage of carers who have been referred for support by their GP. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 19

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard No 22: Older carers and carers of older people will be offered information to support them in making choices and throughout their caring journey. This should be tailored to individual need, accurate, accessible and appropriate. 1a Health and Social Care Trusts will produce a local information pack for carers (complementary to the DHSSPS Carers A-Z) and information in a range of appropriate formats. 1b Trusts will develop a communication plan to demonstrate how both staff and carers are to be made aware of the available information. 100% March 2015 (end of Year 1) and ongoing. 100% March 2015 (end of Year 1) and ongoing. Standard 23: All carers will be signposted to organisations specialising in benefits and financial advice relevant to their role, as early as possible to minimise the impact of caring on their standard of living. 1. Number of carers known to Trusts who have been signposted for financial advice. 2. Feedback from a sample of carers about their experiences regarding financial issues. Establish baseline. March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. 20

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 24: Older carers and carers of older people will have timely access to flexible and responsive services, in order to meet their individual needs. 1. Number of carers who agreed to being referred for a carers assessment. 2. Number of carers who experience flexible and responsive services to enable them to continue their caring role. 40% March 2015 (end of Year 1) 50% March 2016 (end of Year 2) 60% March 2017 (end of Year 3) 70% March 2015 (end of Year 1) 75% March 2016 (end of Year 2) 80% March 2017 (end of Year 3) Standard 25: Older carers and carers of older people will have timely access to appropriate respite breaks to meet different individual needs and circumstances. 3. Carers level of satisfaction with response to instances of emergency support need. 1a The numbers of carers who have been assessed as requiring respite. 1b. The number of carers who receive respite. Baseline established March 2015 (end of Year 1) Improvement target set and monitored. March 2016 (end of Year 2) Establish baseline. March 2015 (end of Year 1)) and ongoing Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. 21

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 25: (continued) Standard 26: All older carers and carers of older people will be supported to look after their own physical and emotional health and wellbeing by all relevant organisations. 2. The number of carers who have been assessed as requiring respite and who do not receive respite. 1. The number of carers who participate in health and wellbeing programmes and events for carers. 2. The number of carers who receive training appropriate to individual needs e.g. manual handling, stress management, knowledge about symptoms and potential impacts from the condition of person being cared for. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) and ongoing Set performance level once baseline established. Establish baseline. March 2015 (end of Year 1) and ongoing Performance targets to be set for when baseline established. Standard 27: Older carers and carers of older people should be treated as equal partners. Consequently carers and their representative organisations will be actively involved in the planning, delivery and monitoring of services. 1. Trusts will have an action plan for carer involvement at all levels in their respective organisations. 2. The number of carers actively participating in commissioning, delivery and evaluation of services. 100% March 2015 (end of Year 1) and ongoing. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. 22

CONDITIONS MORE COMMON IN OLDER PEOPLE STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 28: All older people will be offered annual and opportunistic case-finding checks in Primary Care, to identify individuals at high risk of falling in the future. They will be offered a multi-factorial, evidence based falls and bone health assessment and intervention. Standard 29: All older people presenting to intermediate, or secondary care because of a fall or with an injury resulting from a fall (i.e. fracture) will be offered a multi-factorial, evidencebased falls and bone health assessment and intervention. 1. Staff to assess the agreed range of factors which may cause a person to fall. 2. Individuals identified as at high risk of falling are offered an intervention programme within 4 weeks of index fall 1. Percentage of the total population of older people presenting to intermediate or secondary care because of a fall or with an injury resulting from a fall. 2. Older people presenting to intermediate or secondary care because of a fall are offered a multi factorial, evidence based falls and bone health assessment and intervention within 2 weeks of the index fall. 70% March 2015 (end of Year 1) 80% March 2016 (end of Year 2) 90% March 2017 (end of Year 3) 70% March 2015 (end of Year 1) 80% March 2016 (end of Year 2) 90% March 2017 (end of Year 3) Baseline to be established. March 2015 Performance level set once baseline is established. March 2016 (end of Year 2) March 2017 (end of Year 3) 25% March 2015 (end of Year 1) 50% March 2016 (end of Year 2) 75% March 2017 (end of Year 3) 23

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 29: (continued) 3. Older people presenting to intermediate or secondary care because of a fall, or with an injury resulting from a fall will be asked if they were offered a multi-factorial, evidence based falls and bone health assessment and intervention within 2 weeks of the index fall. 25% March 2015 (end of Year 1) 50% March 2016 (end of Year 2) 75% March 2017 (end of Year 3) Standard 30: All older people admitted to an inpatient fracture service should have routine access to acute orthogeriatric medical support from the time of admission 1. Health and Social Care Trusts providing inpatient fracture services have a designated Orthogeriatrician and provide shared care. 2. Older people admitted with a fracture will have a specialist geriatric assessment within 72 hours. 100% March 2015 (end of Year 1) 100% March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 24

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 31: Older people with continence difficulties will have an assessment carried out by a specialist continence health professional and if appropriate receive onward referral to an integrated continence service. 1. Health and Social Care Trusts should have a lead health professional at a senior level responsible for delivery and development of an integrated continence service. 2. Review of Health and Social Care Trusts written policy document for continence promotion and incontinence management. All Trusts Year 1. March 2015 (end of Year 1) All Trusts Year 1. March 2015 (end of Year 1) Integrated Care pathway development. March 2016 (end of Year 2) Integrated Care pathway in place. March 2017 (end of Year 3) 3. Number of older people who have received specialist assessment for continence issues. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 4. Number of older people who have accessed the integrated continence service in each Trust. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. March 2016 (end of Year 2) & March 2017 (end of Year 3) 25

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 32: All older people who have a major health crisis should be screened for delirium using a validated assessment tool such as the Confusional Assessment Scale shortened version (CAM). 1. Number of patients who develop delirium in hospital. 2. Reduced length of hospital stay for older people who develop delirium. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 3. Each Health and Social Care Trust will have a Mental Health for Older People Liaison Service to co-ordinate and support the delivery of education and training to front line staff. 4. Number of front line staff in hospitals, domiciliary, residential and nursing homes who have participated in structured training re: assessment and management of delirium. 5. Each Health and Social Care Trust will identify the incidence and prevalence of people who develop delirium. 100% March 2015 (end of Year 1) 20% March 2016 (end of Year 2) 30% March 2017 (end of Year 3) Establish baseline. Annually. 26

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 33: All older people should receive a stepped-care approach to the management of delirium. A small minority of people with delirium may require specialist input, or may require to be cared for in a specialised environment. Standard 34: Older people with Advanced Dementia should be identified through existing Primary Care Dementia Registers. These individuals should have the Gold Standards Framework prognostic indicators applied and where appropriate, an End of Life Care Plan should be agreed. 1. Reduction of institutional care as an outcome of an episode of delirium. 2. Reduction in the use of neuroleptic and sedative drugs in the at risk population. 3. Each Health and Social Care Trust will have a Mental Health for Older People Liaison Service to co-ordinate and support the delivery of education and training to front line staff in hospitals, domiciliary care, residential and nursing homes. 1. General Practitioners will identify older people with Advanced Dementia using Gold Standards Framework. 2. General Practitioners will ensure that individuals who have been identified with Advanced Dementia have an Advance Care Plan within 3 months. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 10% March 2015 (end of Year 1) 20% March 2016 (end of Year 2) 30% March 2017 (end of Year 3) 90% March 2015 (end of Year 1) 100% March 2016 (end of Year 2) 27

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 35: All older people who present to primary or secondary care with a sudden unexplained deterioration in their mobility should receive a Comprehensive Geriatric Assessment and access to re-enablement services as appropriate. 1.Primary care and ED referral rates to Geriatric Medicine of older people coded as off feet as primary problem. 2.Number of Comprehensive Geriatric Assessments delivered by Trust. 3. Percentage of older people entering institutional care who have received a Comprehensive Geriatric Assessment as part of the Single Assessment Tool prior to permanent placement. Baseline to be established March 2015 (end of Year 1) 100% March 2017 (end of Year 3) Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. March 2016 (end of Year 2) & March 2017 (end of Year 3) Baseline to be established March 2015 (end of Year 1) Performance level set once baseline is established. March 2016 (end of Year 2) & March 2017 (end of Year 3) 4. Incidence of pressure sores developed in secondary care settings. Establish baseline. March 2015 (end of Year 1) Reduction in incidence of pressure sores by 30% from baseline March 2016 (end of Year 2) Reduction in incidence of pressure sores by 40% from baseline March 2017 (end of Year 3) 28

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 35: (continued) MEDICINES MANAGEMENT 5. Incidence of pressure sores developed in community care settings. Establish baseline March 2015 (end of Year 1) Reduction in incidence of pressure sores by 30% from baseline March 2016 (end of Year 2) Reduction in incidence of pressure sores by 40% from baseline March 2017 (end of Year 3) Standard 36: In partnership with healthcare professionals, older people should be provided with appropriate, safe and effective medicines to enable them to gain maximum benefits from medicines to maintain, or increase their quality and duration of life. 1. Level of prescribing in concordance with local medicines formulary and national standards. 2. Satisfaction reported by people and their carers about medicines information, support for decision making and quality of life. 3. Proportion of people with long term conditions accessing a specific medicines management support programme for concordance. 4. Number of older people with medicines related admissions or re-admissions to hospital. 70% March 2015 (end of Year 1) Ongoing, in tandem with development of the NI formulary. March 2016 (end of Year 2) & March 2017 (end of Year 3) Establish baseline. March 2015 (end of Year 1) Performance levels to be determined once baseline established. Establish baseline. March 2015 (end of Year 1) Performance levels to be determined once baseline established. Establish baseline. March 2017 (end of Year 3) Performance levels to be determined once baseline established. 29

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 37: Older people should have a systematic review of all their medicines at appropriate intervals along the patient pathway to ensure that their medicines continue to be appropriate, and that they participate in the treatment as prescribed. 1. Percentage of older people receiving four or more medicines who are offered a medicines review annually. 2. Percentage of older people residing in care homes receiving a face-to-face clinical medicines review annually. 3. Percentage of older people in secondary care, who have had their medicines list checked and verified as accurate on admission. 80% March 2015 (end of Year 1) 80% March 2016 (end of Year 2) 80% March 2017 (end of Year 3) Establish baseline. March 2015 (end of Year 1) Performance levels to be determined once baseline established. Establish baseline. March 2016 (end of Year 2) Performance levels to be determined once baseline established. 4. Review of regional minimum data set arrangements for medicines-related information for use when older people move across care settings is agreed. 5. Medicines with highest risk for older people are monitored appropriately in accordance with local guidance. Progress of arrangements. March 2016 (end of Year 2) Arrangements completed. March 2017 (end of Year 3) Establish baseline. March 2016 (end of Year 2) Performance levels to be determined once baseline established. March 2017 (end of Year 3) 30

TRANSITIONS OF CARE STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 38: Older people should be able to access a single point of contact for information and advice about all aspects of community support and health and social care services when they first start to need help to maintain their independence. Standard 39: Older people should be offered a period of reablement to regain their optimum level of independence and confidence before any assessment is made for longer term supports. 1. Number of older people who have accessed the single point of contact and what information, or community support provided. 2. Number of older people who have accessed the single point of contact and required onward referral to health and social care services. 1. Number of older people who no longer require a home care service after a period of re-ablement. 2. Number of older people, who still need a home care service after a period of reablement. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 3. The number of weekly care package hours at the end of re-ablement. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 31

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 40: Older people with health problems should be identified early to maximise independence and reduce crisis. Treatment and care should be delivered in the most appropriate setting. 1. Number of older people receiving urgent care at home. 2. Outcomes for older people receiving urgent care at home. Establish baseline. March 2016 (end of Year 2) Performance level set once baseline is established. 100% March 2016 (end of Year 2) Standard 41: Older people with complex needs should be screened and appropriately managed by specialist staff during episodes of general hospital care. 1. Reducing length of hospital stay for older persons with complex needs. 2. Percentage of older people admitted directly to care homes (for the 1 st time from a general hospital). 3.There is a documented discharge plan for each older person with complex needs discharged from a general hospital, including details of communication with the patient, his/her family carer and professionals outside hospital. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 32

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 42: Older people with complex health needs including people with Dementia, or mental health needs should be offered comprehensive, specialist assessments and a period of rehabilitation before consideration is given to the need for long term care. 1. Number of people with a comprehensive, person-centred, specialist assessment. 2. Number of older people who accessed rehabilitation programmes. 3. Number of older people who had a comprehensive, person-centred, specialist assessment and period of rehabilitation with the following outcomes: a. returned home with no care package; b. returned home with a care package (please specify number of hours of domiciliary support) c. returned to care home; d. admitted to care home for the first time. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 33

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 43: Older people who live in nursing homes should be able to access appropriate medical and other specialist supports to ensure their needs are met safely, effectively including palliative care and end of life care planning. Standard 44: All older people identified to have end of life care needs should have a key worker and access to effective palliative and supportive care services for end of life needs. 1. Number of residents seen by specialist staff in nursing homes. 2. Unscheduled hospital admissions of Care Home residents. 1. Number of patients and family members, or friends who participate in person-centred training to promote optimal health and wellbeing through information, counselling and support for people with end of life care needs. 2. Patient identified to have palliative and end of life care needs allocated a key worker. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 3. Number of older people dying in hospital having been admitted from Nursing Homes. Establish baseline March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. 34

STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 44: (continued) Standard 45 (Generic): All people with advanced progressive incurable conditions, in conjunction with their carers, should be supported to have their end of life care needs expressed and to die in their preferred place of care 4. All patients identified to have palliative and end of life needs should have the opportunity for holistic assessment and advance care planning. 1. Percentage of the population that is enabled to die in their preferred place of care. 2. Percentage of population with an understanding of advance care planning Performance level set once baseline is established. March 2015 (end of Year 1) Establish baseline March 2014 Performance levels to be determined once baseline established March 2015 Establish baseline March 2014 Performance levels to be determined once baseline established. March 2015 Standard 46: Older people with mental health conditions or dementia should, from an early stage, access services and environments that provide skilled assessment, treatment and care enabling them to maintain as much independence as possible. 1. Trusts should have detailed information on all services for people with mental health conditions including dementia, highlighting linkages, gaps and usage. 2. Trusts should provide detailed information on all services for older people with dementia and mental health conditions. This should show the full continuum of services in community and hospital and include activity and outcomes. This needs to show evidence of shifts towards prevention approaches. 100% March 2015 (end of Year 1) and ongoing. 100% March 2015 (end of Year 1) and ongoing. 35

SECTION 1 INTRODUCTION TO SERVICE FRAMEWORKS Background The overall aim of the Department of Health, Social Services and Public Safety (DHSSPS) is to improve the health and social wellbeing of the people of Northern Ireland (NI). In support of this the Department is developing a range of Service Frameworks which set out explicit standards for health and social care that are evidence based and capable of being measured. The first round of Service Frameworks focus on the most significant causes for ill health and disability - cardiovascular health and wellbeing; respiratory health and wellbeing; cancer prevention, treatment and care; mental health and wellbeing; and learning disability. In addition to the Service Framework for Older People, work has also commenced to develop a Service Framework for Children and Young People. See Appendix A Service Frameworks have been identified as a major strand of the reform of health and social care services and provide an opportunity to: strengthen the integration of health and social care services; enhance health and social wellbeing, to include identification of those at risk, and prevent/ protect individuals and local populations from harm and /or disease; promote evidence-informed practice; focus on safe and effective care; and enhance multi-disciplinary and inter-sectoral working. 36

Aim of Service Frameworks Service Frameworks will set out the standards of care that service users, their carers and wider family can expect to receive in order to help people to: prevent disease or harm; manage their own health and wellbeing, including understanding how lifestyle affects health and wellbeing including the causes of ill health and its effective management; be aware of what types of treatment and care are available within health and social care; and be clear about the standards of treatment and care they can expect to receive. Service Frameworks will be used by a range of stakeholders including commissioners, statutory and non-statutory providers, and the Regulation and Quality Improvement Authority (RQIA) to commission services, measure performance and monitor care. The Frameworks will identify clear and consistent standards informed by expert advice, research evidence and by national standard setting bodies such as the National Institute for Health and Clinical Excellence (NICE) and the Social Care Institute for Excellence (SCIE). The auditing and measuring of these standards will be assisted by the Guidelines and Implementation Network (GAIN) which will facilitate regional audit linked to priority areas, including Service Frameworks. The standards, in the context of the 10 year Quality Strategy (1), will aim to ensure that health and social care services are: i. Safe health and social care which minimises risk and harm to service users and staff; ii. Effective health and social care that is informed by an evidence base (resulting in improved health and wellbeing outcomes for individuals and communities), is commissioned and delivered in an efficient manner (maximising resource use and avoiding waste), is accessible (is timely, geographically (1) Quality 2020 A 10-Year Quality Strategy for Health and Social Care in Northern Ireland 37

reasonable and provided in a setting where skills and resources are appropriate to need) and equitable (does not vary in quality because of personal characteristics such as age, gender, ethnicity, race, disability (physical disability, sensory impairment and learning disability), geographical location or socio-economic status). iii. Person-centred health and social care that gives due regard to the preferences and aspirations of those who use services, their family and carers and respects the culture of their communities. A person of any age should have the opportunity to give account of how they feel and be involved in choices and decisions about their care and treatment dependent on their capacity to make decisions. In absence of the capacity to make decisions they should listen to those who know and care for the person best. Involving and Communicating with Service Users, Carers and the Public The Department has produced guidance, Strengthening Personal and Public Involvement in Health and Social Services (2), which sets out values and principles which all health and social care organisations and staff should adopt when engaging with the public and service users. These include the need to involve people at all stages in the planning and development of health and social care services. This policy position has been strengthened by the introduction of the Health and Social Care (Reform) Act (Northern Ireland) 2009 and the statutory duty it places on HSC organisations to involve and consult with the public. (Article 19) It is important that the views of service users and carers are taken into account when planning and delivering health and social care. The integration of the views of service users, carers and local communities into all stages of the planning, development and review of Service Frameworks is an important part of the continuous quality improvement and the open culture which should be promoted in HSC. (2) DHSSPS (2007) Guidance on Strengthening Personal and Public Involvement in Health and Social Care (HSC SQSD) 29/07) http://www.dhsspsni.gov.uk/hsc_sqsd_29-07.pdf 38

The Department is committed to involving those who use older people s services, their carers and wider families. Through the proactive involvement of the service users and carers in the planning of Service Frameworks, it is hoped that concerns and ideas for improvement can be shared and that the standards developed in partnership with service users, carers and the public will focus on the issues that really matter to them. The Public Consultation on the Service Framework for Older People has made an important contribution to the process. It is also important that Service Frameworks provide service users and carers with clear and concise information, which is sensitive to their needs and abilities, so that they can understand their own health and wellbeing needs. To facilitate this, easy access versions have been made available for all Service Frameworks. Frameworks will also be available in a range of other formats e.g. Braille, large print and audio tape. The Department will also consider requests for other formats or translation into ethnic minority languages. People are ultimately responsible for their own health and wellbeing and that of their dependents, and it is important that service users, their carers and wider family are made aware of the role they have to play in promoting health and wellbeing. Involving Other Agencies in Promoting Health and Wellbeing Improving the health and wellbeing of the population requires action right across society and it is acknowledged that health and wellbeing is influenced by many other factors such as poverty, housing, education and employment. While Service Frameworks set standards for providers of health and social care services it is essential that HSC services work in partnership with other Government departments and agencies both statutory and nonstatutory to seek to influence and improve the health and social wellbeing of the public. The Service Framework for Older People provides a foundation for these processes. People, who use health and social care services, including services for older people, may have complex needs which require inputs from a range of health and social care professionals and other agencies. The benefits of multidisciplinary team working and multiagency working, including voluntary and community organisations, are well recognised and it is a key component of 39

decision making regarding prevention, diagnosis, treatment and ongoing care. This will be a key theme underpinning the development and implementation of Service Frameworks. Data Collection As Service Frameworks are implemented it is important that timely, accurate information is available to support decision-making and service improvement. To support this, data sources are identified, early in the development stage, to match the Key Performance Indicator (KPI) data definitions. It is through the data source that progress can be monitored. Where robust baseline data is not available Frameworks will be looking to audits, including Self- Assessment Audit Tools (SAATs), to gather information, establish baselines and set future performance levels. Multidisciplinary Working Patients and service users often have complex needs, which cannot be addressed by a single professional. The benefits of multidisciplinary team working are well recognised and it is a key component of effective decision-making. Multidisciplinary working will be a key theme underpinning the development and implementation of service frameworks. Research and Development It is important that Service Frameworks are based on valid, relevant published research, where available, and other evidence. Education and Workforce Education and workforce development occur at individual, team, organisational, regional and national levels: they are part of the drive to promote quality. The ongoing development and implementation of Service Frameworks will influence the education and training agenda and curricula content for all staff involved in the delivery of health and social care. This will require a commitment to lifelong learning and personal development alongside a focus on specific skill areas to ensure that newly qualified and existing staff are in a position to deliver on quality services. 40

Leadership Effective leadership is one of the key requirements for the implementation of Service Frameworks and will require health and social care professionals from primary, community and secondary care to work together across organisational boundaries, including other Governmental departments and the voluntary, community and independent sectors. It is essential that Service Frameworks are given priority at senior, clinical and managerial level and implemented throughout all HSC organisations. Affordability Extensive discussions have been held with key stakeholders on the overall costs of delivering the Service Framework for Older People in the context of the very significant challenges facing health and social care services. Many of the standards do not require additional resources and should be capable of delivery by optimising the use of existing funding. Where there are additional costs associated with specific standards, performance indicators and targets will be reviewed and adjusted as necessary, in the light of the available resources in any one year. Securing additional funding that may be needed to advance some standards will undoubtedly create challenges. However, Service Frameworks constitute the distillation of the best advice and guidance available and there is great value in setting out our aspirations to improve quality in the care of older people, even if we are cannot commit to achieving every standard fully or as quickly as we would like. Even in the most difficult of times we must continue to set challenging targets in an effort to improve services. The Department will work closely with the HSC Board, Public Health Agency and other stakeholders, in developing an achievable, prioritised implementation plan for this Service Framework that will deliver real benefits and improved quality of services. 41

SECTION 2 THE SERVICE FRAMEWORK FOR OLDER PEOPLE Introduction For the purpose of this Service Framework the focus will be on people over 65 whilst taking account of the needs of those over 50, where appropriate, particularly in relation to preventative measures. The number of older people over 65 is an increasing proportion of the population of Northern Ireland. This is in line with global trends which bear testimony to the major advances which have been made in increasing life expectancy and promoting healthy ageing. There are currently 260,500 people aged over 65 in our population, an increase of 18% since 2000, and this number is expected to increase by 13% by 2015. This will include a projected rise of 24% in the number of people aged over 85. Ageing brings with it an increased likelihood of some degree of disability and dependency and older people are the main users of health and social care services. Many medical conditions such as stroke, vascular disease or dementia are not limited to this population but occur more frequently in those over 65. The vast majority live independently, whilst others may require some support from family, carers, statutory or independent sector services. Older people make a huge social, political, cultural and economic contribution to society and will become an increasingly influential constituency as a result of demographic change. On an average daily basis: two thirds of acute hospital beds are occupied by people over 65; 85% of clients getting intensive domiciliary care were aged 65 and over. On a weekly basis: An estimated 233,273 contact hours of domiciliary care are provided by Health and Social Care Trusts; Approximately 23,389 clients weekly receive domiciliary care; 9,677 people over 65 live in residential care or nursing homes. These demands are likely to increase and we must review how services are focussed, designed and organised if they are to be 42

addressed within current, and prospective, resource limitations. This Framework demonstrates Departmental commitment to tackling these challenges. Identifying the Scope of the Project There is a need to decide how to encompass the concept of older people in a way that makes the development of standards coherent, connected and comprehensive. Service Frameworks based on medical conditions follow a relatively logical, common sequence from prevention through to diagnosis, and treatment whereas population based ones do not neatly conform to this logical progression. In this Framework the issue is compounded by the fact that standards which might overlap with other condition/ population based Frameworks have already been developed. In order to avoid duplication of effort and reflect the complexity and variety of the service needs of older people an approach has been adopted to systematically capture and logically outline areas of activity where new standards can contribute to enhancing the health and wellbeing of older people based on the seven themes outlined below. The Framework does not purport to specify an exhaustive suite of standards to address all of the main medical conditions pertinent to older people. It needs to read in conjunction with other relevant Frameworks which deal with associated considerations such as stroke, respiratory conditions and cancer for example. There is also scope for some internal cross-referencing and comparisons within the Framework to obtain a more comprehensive understanding of the approach to issues such as falls and dementia. The Service Framework for Older People sets standards in relation to: 1. Person-centred Care - which emphasises the importance of people being involved in planning a response to their care needs, of being supported, being treated fairly and with respect in the process. It reinforces the extent to which the framework is committed to the older person being central to care planning. 2. Health and Social Wellbeing Improvement - which underlines the value of preventative strategies and the capacity for people to shape their own life chances/health 43

outcomes and, in so doing, redefine some conditions/events in terms of prevention rather than treatment (e.g. falls, osteoporosis). 3. Safeguarding - which decisively endorses and promotes the new emphasis on protecting vulnerable adults and older people against neglect, abuse or exploitation. 4. Carers - which firmly supports the centrality of the carer role in service planning and delivery by according it parity with many of the other interventions encompassed in the standards document. 5. Conditions more Common in Older People - which focuses selectively on a number of conditions where concerted efforts at adherence to the standards would significantly improve the health and wellbeing of older people. 6. Medicines Management - which stresses the importance of systems to ensure prescribing adheres to relevant guidance and highlights the importance of maximising health gains, patient participation in decision making, risk reduction, good record keeping and review. 7. Transitions of Care - which identifies significant points in the individual s transition through the care system where there is significant potential to improve the care experience and effective use of resources. The Service Framework for Older People is initially for a three-year period from 2013 2016. It will be the subject of further review and continuing development as a living document as performance indicators are achieved, evidence of changed priorities emerges and new performance indicators are identified. 44

Process for Developing the Service Framework for Older People Framework development has been overseen by a multidisciplinary Programme Board, which is jointly chaired by the Chief Medical Officer and Deputy Secretary of the DHSSPS. The Service Framework for Older People has been developed by a Project Team with seven sub-groups, led by individuals with recognised expertise in the particular thematic areas upon which it is based, and an Older People s Reference Group. Details of the groups and membership are outlined in Annexes D, E and F. At the outset of the process the importance of incorporating the perspective of older service users was recognised. This led to the establishment of the Older People s Reference Group which was an integral part of the overall structure and an innovative addition to Service Framework development. The formation of the Group initially was facilitated by the Patient Client Council (PCC), Carers (NI) and Age (NI) with the PCC providing support to the forum. The Reference Group comprised of 17 older people from diverse backgrounds with recent and current experience of using the services under consideration as patients, clients and carers. Members were active in communities of older people across Northern Ireland and were able to reflect genuine patient and carer views on the developing standards. The Group was a pioneering initiative and became a significant component of the project structure with the Chairperson being a member of the Project Board. It formally quality assured the individual outputs of the various work-streams in a series of workshops and produced a composite report containing a number of recommendations which had a significant impact on the final Framework document. A summary of this work is contained in Annex F and a copy of the report is available at: www.patientclientcouncil.hscni.net 45

Values and Principles The Service Framework has drawn on a wide range of quality standards, legislation, policy and procedural guidance to identify the values and principles which should underpin the delivery of services for older people. These have influenced standards development, will be actively promoted through the process of implementation and are outlined below: older people have a right to equality of access to services; older people and their families are fully involved in the assessment of their needs; listening to, and engaging with, older people and their carers and families is vital to ensure full participation in care planning; services are tailored to individual needs and are designed to empower older people and respect their dignity; older people and their families should be engaged as partners in problem solving and risk management to allow them to live as full and independent lives as possible; safeguarding and promoting the welfare of older people who are abused or at risk of abuse or neglect is a priority when decisions are made about access to and eligibility for services. Services should be designed to promote and safeguard wellbeing; the promotion of independence, self help and self directed support through the active participation of individuals, their carers and the wider community will lead to an empowerment and partnership between those who utilise health and social care services in old age and those who are delivering it. Policy and Legislative Context Even within the relatively short lifespan of the Project to date the pace of change within health and social care and the wider world has been, challenging The financial context has changed radically and policy positions are being constantly redefined to take account of this. So even though Service Frameworks are designed to cover a three year timescale, in the first instance, it has not been easy, to anchor the work, with a high degree of confidence, in policies or pronouncements which will provide a solid foundation for future work. The Project Team has reviewed legislative, policy and service developments which underpin the Framework and a summary of this work is outlined in Annex I. This section briefly outlines a number of recent or current developments which will have a particular relevance for the implementation of the standards. 46

An important starting point is the OFMDFM strategy for older people, Ageing in an Inclusive Society, which outlined the direction of travel for older people s services and will underpin the forthcoming Older Peoples Strategy which is expected t oreinforce the: emphasis on positive ageing; involvement of older people in decision making; promotion of independence; need for equality of access to services; better coordination of services; focus on prevention. are strongly reflected in the Framework and will shape and guide implementation. In addition, the publication by the Department of the Living with Long Term Conditions policy framework helpfully interfaces with and reinforces many of the themes contained within this document. At yet another strategic level the implementation of the regional Dementia and Physical and Sensory Disability strategies is likely to impact on the delivery of services for older people. Whilst this may be severely constrained, in both cases, by resource constraints they identify a range of actions which have the potential to improve the service experience for many people on a multiagency basis by promoting prevention and awareness raising. These limitations and possibilities are reflected in the service standards. The recent HSCB Review Transforming Your Care has outlined more starkly the radical reshaping of services which need to be proactively addressed in order to meet new demands and make best use of available resources. It highlights the daunting scale of the challenge within older people s services in particular which must be addressed. Many of the standards contained in this Framework are designed to contribute to achieving the degree of change which is required. The appointment of a Commissioner for Older People for Northern Ireland is welcomed as an indication of the significance of this agenda and in terms of the weight and influence that the office is likely to apply in support of moving this agenda forward. 47

Equality Screening The Framework has been screened to take account of Section 75 of the Northern Ireland Act 1998 and any potential impact that the Framework might have on Human Rights. It is the recommendation of the Project Team that the Framework does not negatively impact on equality of opportunity and therefore does not require a full Equality Impact Assessment. Consistency with other Documents The Service Framework for Older People has taken cognisance of reports and documents that have been or are being developed by DHSSPS and other regional groups, including: Investing for Health strategies; The Quality Framework as outlined in Best Practice - Best Care (2001); The Reform and Modernisation of HSC; Personal and Public Involvement (PPI) (DHSSPS, 2007); National Institute for Health and Clinical Excellence Guidance. Human Rights and Social Inclusion A key priority for health and social care services and the wider community is to tackle stigma, discrimination and inequality and to empower and support older people and their families to be actively engaged in the process. This is underpinned by legislation from Europe and the United Kingdom (UK). A summary of all the relevant legislation can be found in Promoting Social Inclusion, Human rights, as enshrined in the Human Rights Act (1998) UK, derive from the fundamental principles that: human beings have value and should be treated equally based on the fact that they are human beings first and foremost; and human worth is not based on either capacity or incapacity. Human rights include the right to life, liberty and security and respect for a private and family life. 48

Terminology Inevitably, a Framework which encompasses the variety of themes and complexity of services as this document does will inevitably contain organisational jargon and terminology which may not always be interpreted consistently by professionals, agencies and members of the public. A glossary of terms is included at Annex B to improve accessibility and understanding of the standards contained in the following sections of the Framework. How to read the rest of this document (Standards Template) Each standard is presented in the same way and Figure 1 shows the information that is included. A brief explanation is provided for each section, as appropriate, to explain the logic and rigour applied by sub- group leads in order to achieve consistency and internal coherence in developing the portfolio of standards. In the Service Framework for Older People each standard is accompanied by a statement on what the standard is intended to achieve. Each standard sets out the evidence base and rationale for the development of the standard, the impact of the standard on quality improvement as well as the performance indicators that will be used to measure that the standard has been achieved within a specific timeframe. Each standard is presented in the same way. 49

Figure 1: Explaining the standards Overarching Standard This is intended to be a brief description of the standard and, in order to emphasise the commitment to being person-centred, rather than service-centred and to equity of provision, a common terminology has been adopted, wherever possible, to emphasise that All older people should have... Rationale This is a short section that outlines why/how the standard will make a difference for people services. Evidence This includes brief references for the research evidence or guidance that the standard is based on. Website addresses are included to facilitate more detailed access to information. Quality Dimensions The six standard Service Framework quality criteria are: Person-centred, Safety, Timeliness, Effectiveness, Efficiency and Equity. Work-streams exercised their own judgment in identifying all or some of these which were relevant to a particular standard. Performance indicator This information will be monitored to show if the standard is being delivered. Data Source This identifies where the information will be derived from. Anticipated performance level This describes how well the service must perform against this indicator. Date to be achieved by This specifies when the anticipated performance level should be reached. 50

Each standard sets out the evidence base and rationale for the development of the standard, the impact of the standard on quality improvement as well as the performance indicators that will be used to measure that the standard has been achieved within a specific timeframe. The standards are colour coded for ease of reference, for example the standards relating to Person-centred Care are green Person-centred Care Health and Social Wellbeing Improvement Safeguarding Carers Conditions More Common in Older People Medicines Management Transitions of Care 51

SECTION 3 - PERSON CENTRED CARE Overview of Person-centred Care Standards Introduction: The standards set out in this section are about treating older people with dignity and respect and as individuals with the same rights as any other citizen to receive flexible and responsive services that meet their assessed needs and preferences. These standards seek to place the older person and their carers at the centre of the decision making process and to ensure that each person is enabled to make informed choices about the care and treatment they require and the way in which they receive it. A person-centred care service is one that promotes independence, equality and social inclusion. It requires an organisational culture that actively involves older people in identifying their needs, designing services and helping find solutions. It is an approach that achieves success through effective relationships between the older person, their carers and staff who are appropriately trained and motivated. 1. Engagement and Choice: Older people should be treated as individuals, be enabled to engage fully in making informed choices about their own care/ treatment and have control over the way in which it is delivered. 2. Equality of Opportunity and Eliminating Discrimination: Older people should expect the same opportunity of access to assessment, care and treatment as any other user of health and social care services. 3. Communication (Generic Standard): All patients, clients, carers and the public should be engaged through effective communications by all organisations delivering health and social care. 4. Involvement (Generic Standard): All patients, clients, carers and the public should have opportunities to be actively involved in the planning, delivery and monitoring of health and social care at all levels. 52

5. Advocacy: Older people should have access to independent advocacy that will provide information, advice and support to enable them to make informed choices and be fully involved in decisions that affect them. 6. Independent Advocacy (Generic Standard): Users of health and social care services and their carers should have access to independent advocacy as required. 53

Standard 1: Engagement and Choice All older people should be treated as individuals, be enabled to engage fully in making informed choices about their own care/ treatment and have control over the way in which it is delivered. Rationale A person-centred approach to care and service delivery places the individual who needs support at the centre of the assessment, planning and review processes as it takes as a starting point that they are expert in understanding their own needs. In order to benefit from this approach, the individual needs to have access to a key worker who works with them and other relevant partners/ organisations to promote their aspirations, lifestyle, independence and autonomy. The professional s expertise is in clinical, technical and social knowledge and skills use of potential effective treatments/ resources and engaging the individual (family members, care partners and friends if appropriate) in resolving difficulties together. Person-centred care requires a cultural shift in health and social services from a diagnostic/assessment model to a partnership/person-centred model of care where the individual has access to information, advocacy and advice that helps them make informed decisions about their care and support. Older people should be fully involved in identifying their needs, designing services and finding solutions to maintain their independence, privacy, fulfilment, choice and safety and promoting opportunities for social inclusion and community engagement. 54

Each person has his/her own unique set of values, experiences and expectations. A person-centred service puts the older person and their carers at the centre of the process of assessing their needs. It does not focus on the person s suitability for a particular service but it requires integrated services that cross professional and organisational boundaries to promote their independence and autonomy. Person-centred care should be a whole system approach that ensures flexible and innovative care for individuals, their family, care partners and friends. Evidence 1. Department of Health (2001) National Service Framework for Older People London: Department of Health. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyand Guidance/DH_4003066 2. Department of Health (2010) Personalisation through Person Centred Planning London: Department of Health. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyand Guidance/DH_115175 3. Department of Health (2007) Putting People First: A Shared Vision and Commitment to the Transformation of Adult Social Care. London: Department of Health. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyand Guidance/DH_081118 4. McCormack. B, Mc Cance, T and Slater, P (2008) Personcentred Outcomes and Cultural Change. in: International Practice Development in Nursing and Healthcare. Blackwell, pp. 189-214. 5. McCormack. B, et al. (2010) Developing Person-centred Practice: Nursing Outcomes Arising from Changes to the Care Environment in Residential Settings for Older People. International Journal of Older People Nursing. Volume 5. Issue 2. pp.93 107. 6. Nolan, M. et al (2004) Beyond Person-centred Care: A New Vision for Gerontological Nursing, Journal of Clinical Nursing, Vol 13, pp 45-53, Oxford: Blackwell. 55

7. Office of First Minister and Deputy First Minister (2005) Ageing in an Inclusive Society: Promoting the Social Inclusion of Older People. http://www.ofmdfmni.gov.uk/age-ageing-in-an-inclusive-society 8. Patmore. C, McNulty. A. (2007) Caring for the Whole Person: Home Care for Older People which Promotes Well-being and Choice. www.well-beingandchoice.org.uk 9. Social Care Institute for Excellence (2006) Personalisation: A Rough Guide. Guide 20. http://www.scie.org.uk/publications/reports/report20.pdf Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Quality Dimensions Person-centred - Older people will receive a flexible service, tailored to their needs and preferences and will have been involved in the decisions regarding what, when and how their care is delivered. Timeliness - Older people will receive a service at a time and in a fashion that is right for them and which has been agreed by them. Effectiveness - Older people can expect to experience better outcomes from a service that has been tailored to meet their particular needs. Efficiency - Available resources can be better targeted to ensure maximum benefit to the older person, thereby reducing unnecessary costs/ waste. Equity - Older people will have equality of access to care and treatment similar to any other citizen and will receive the type of care that they want, at a time and in a fashion that meets their individual needs and preferences. 56

Performance Indicator 1. Trusts will have a Person-centred Care Module as part of Corporate Induction Training. 2. Assessment of need and care planning is developed collaboratively between staff and older people on a multidisciplinary basis. 3. Older people receive support / services to meet their individual needs at the right time. Data Source Corporate Induction Training Programmes Service user and carer feedback Trust analysis of compliments and complaints from older people Service user survey Anticipated Performance Level Date to be achieved by All Trusts March 2015 (end of Year 1) Establish baseline Performance level set once baseline is established Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) March 2015 (end of Year 1) 57

Standard 2: Equality of Opportunity and Eliminating Discrimination All older people should expect the same opportunity of access to assessment, care and treatment as other users of health and social care services. Rationale Evidence suggests that age discrimination occurs in different guises and at different levels across all health and social care services. In Northern Ireland, older people report experiences of being treated less favourably with regard to waiting lists, operations and treatment of their illnesses. Older people are not a homogenous group. Their diversity and differences need to be recognised and respected. Section 75 of the Northern Ireland Act 1998 places a statutory duty on public authorities, in fulfilling their functions, to promote equality of opportunity. A key aim of all organisations working with older people is to promote equality of opportunity and full participation in civic life. It is of critical importance that ageism is not tolerated and that older people have equal access to facilities and services that meet their needs and priorities. Everyone, regardless of age, has the right to fair and equal access to appropriate health and social care services. Evidence 1. Age Concern and Help the Aged (2009) Response to the National Review of Age: Discrimination in Health and Social Care Call for Evidence, London: Age Concern and Help the Aged. 2. Access, Research, Knowledge (2008) Northern Ireland Life and Times Attitudes to Older People, Belfast. Access, Research, Knowledge. www.ark.ac.uk/pdfs/policybriefs/policybrief2.pdf 3. Carruthers, I and Ormondroyd, J (2009) achieving Age Equality in Health and Social Care: A Report to the Secretary of State. www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh _107278 4. Centre for Policy on Ageing (2010) Review of Age Discrimination in 58

Primary Health Care, Secondary Health Care, Mental Health and Social Care Services in the UK. London: Centre for Policy on Ageing. http://www.cpa.org.uk/information/reviews/reviews.html. 5. Equality Commission for Northern Ireland (2005) Section 75 of the Northern Ireland Act 1998 Guide to the Statutory Duties. http://www.equalityni.org/archive/pdf/guidetostatutoryduties0205.pdf 6. Northern Ireland Human Rights Commission (2006) Get in on the Act: A Practical Guide to the Human Rights Act for Public Authorities in Northern Ireland. http://www.nihrc.org/dms/data/nihrc/attachments/dd/files/45/human_rights_reportnew1-3.pdf 7. The Office of the First Minister and Deputy First Minister (2005) Ageing in an Inclusive Society: Promoting the Social Inclusion of Older People. www.ofmdfmni.gov.uk/ageingreport-2.pdf LAW CENTRE ref? Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Quality Dimensions Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Person-centred - Older people will receive the care and treatment they need based on clinical/professional judgement and with the full cooperation and agreement of the older person. Timeliness - Older people should have timely access to services based on clinically assessed need. Effectiveness - Timely and fair access to services should enhance recovery rates and improve outcomes for the older person. Efficiency - Improved access and outcomes should reduce costs associated with longer term recovery and rehabilitation. It may also reduce legal costs associated with discrimination and implications for the reputation of the organisation that fails to ensure equality of opportunity. Equity - Differences in treatment /services will be justified from a 59

clinical/social and legal perspective equality based on need. Performance Indicator 1. Older people experience equal access to assessment, care and treatment 2. Review of Trusts Equality Policies that safeguard and promote Human Rights Data Source Service user feedback Anticipated Performance Level Establish baseline Performance level set once baseline is established Date to achieve by March 2015 (end of Year 1) Trust Report All Trusts March 2015 (end of Year 1) 60

Standard 3 : Communication (Generic) All patients, clients, carers and the public should be engaged through effective communications by all organisations delivering health and social care. Rationale Effective communication (clear, accessible, timely, focused and informative) has a significant impact on all aspects of care provision from disease prevention, to diagnosis, to self-management of long-term conditions. Poor communication is a significant factor in most complaints against HSC organisations. Evidence 1. Guidance on strengthening Personal and Public Involvement in Health and Social Care (DHSSPS, 2007) http://www.dhsspsni.gov.uk/hsc sqsd 29-07.pdf 2. Good Medical Practice (GMC, 2013) http://www.gmc-uk.org/guidance/good_medical_practice.asp 3. Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland Order) 2003: www.dhsspsni.gov.uk/hpss_qi_regulations.pdf Responsibility for delivery / implementation Health and Social Care Board Public Health Agency HSC Trusts Primary Care Delivery and Implementation Partners DHSSPS DE Other service providers Service Users & carers 61

Quality Dimensions Safe - Good communication with patients/clients/carers enables adequate understanding of, consent to and compliance with treatment and care and contributes to audit and monitoring. Effective - Health and care outcomes themselves are enhanced through improved patient partnership and dialogue, including, but not limited to diagnosis, self-referral, health promotion, disease prevention and management of long term conditions. Good communication helps to deliver and sustain appropriate patient/client/carer access to services and a clear understanding of the role and responsibilities of the service user in achieving health and care outcomes. Person-centred - Person-centredness cannot be delivered or claimed in the absence of good communication with service users. Good communication is a prerequisite of person-centredness. As a universal requirement, good communication helps to ensure input by all service users on all aspects of the services they receive assisting in the highlighting of gaps in provision and areas for improvement. Performance Indicator 1. Percentage of patients and clients expressing satisfaction with communication Data source Patient and Client Experience monitoring report Annual Accountability Report Anticipated Performance Level Establish baseline and set target Report percentage increase of patient and client satisfaction with communication Report percentage increase of patient and client satisfaction with communication Date to be achieved by March 2014 March 2015 March 2016 62

Standard 4: Involvement (Generic) All patients, clients, carers and the public should have opportunities to be actively involved in the planning, delivery and monitoring of health and social care at all levels. Rationale Actively involving patients and the public in the planning and provision of health care in general has been noted to bring many advantages to both those who receive and those who provide care. These include: Increased patient satisfaction and reduction in anxiety with positive health effects Improved communication between service users and professional staff Better outcomes of care with greater accessibility and acceptability of services Bridging of the gap between those who avail of services and those who provide care Recognition of the expertise of the recipient of care developed through experience Evidence 1. Guidance on strengthening Personal and Public Involvement in Health and Social Care (DHSSPS, 2007) http://www.dhsspsni.gov.uk/hsc sqsd 29-07.pdf 2. Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 http://www.dhsspsni.gov.uk/hpss_qi_regulations.pdf 3. A Healthier Future 2005-2025 (DHSSPS) http://www.dhsspsni.gov.uk/show_publications?txtid=7282 4. Healthy Democracy (NHS National Centre for Involvement, 2006) http://www.nhscentreforinvolvement.nhs.uk/index.cfm?content=90 63

Responsibility for Delivery/ Implementation Health and Social Care Board Public Health Agency HSC Trusts Primary Care Delivery and Implementation Partners Other Service Providers Advocacy Organisations RQIA Families & Carers Quality Dimensions Safe - Personal and Public Involvement enhances governance at all levels through the routine inclusion of patient experience and the issues arising from this in the planning, delivery and monitoring of services. Effective involvement ensures that the level and means of engagement with service users and the public are appropriate to the needs of the service and of service users. Effective - The development of partnerships with service users and the public contributes to Health and care outcomes generally. It is a prerequisite of success where patient and public participation is the decisive factor in achieving the outcome for example, in health promotion and disease prevention. Well developed and widespread Personal and Public Involvement contributes to equitable services through the active engagement of service users and the public in planning, priority setting and decision-making. Person-centred - Personal and public involvement is a necessity for the successful development of patient centred services. Performance Indicator Data Source Anticipated Performance Level Date to be achieved by 1.Percentage of job descriptions containing PPI as responsibility Year 1: senior and middle management Year 2: Audit sample of job descriptions Establish baseline and set target Monitor progress 100% - in all new job descriptions. March 2014 March 2015 March 2016 64

designated PPI leads at all levels of HSC organisations Year 3: all new job descriptions 2.Percentage of patients and clients expressing satisfaction Patient and Client Experience monitoring report Annual Accountability Report Annual Accountability Report Establish baseline and set target Report percentage increase of Patient and Client satisfaction Report percentage increase of Patient and Client satisfaction March 2014 March 2015 March 2016 3.Percentage of staff who have gained PPI training (details to be agreed for 2014/2015) Training Report Conduct training needs assessment for PPI. Commission design of PPI training programme Establish baseline and set target Monitor percentage of staff trained at different levels in PPI March 2014 March 2015 March 2016 65

Standard 5: Advocacy All older people should have access to independent advocacy that provides information, advice and support to enable them to make informed choices and be fully involved in decisions affecting them. Rationale The purpose of advocacy is to empower individuals to act for themselves, to protect their interests and give them a stronger voice to ensure that their views and experiences are adequately represented. Older people state that they often need more than signposting. They also need guidance; support and involvement in developing services to ensure their needs and aspirations are met. This can help them remain independent and in control of their own lives. It is important that older people have access to independent advocacy where they do not have support from family, friends and carers do not wish to involve them or when they are living away from home or in institutions. There may be difficulties or conflicts of interest when professional opinion is contrary to their views. They may not be able to express their views and opinions about the care, treatment and support they receive or want and may need to challenge ageism, potential or actual abuse and other forms of discrimination which could affect their lives, health and wellbeing. Older people may have a greater need for formal and informal care due to their decline in health and consequent social isolation. Their impaired abilities may have caused them to move to a new area where they have few or no social support networks. An independent advocacy service provides the means whereby the older person can express their views and, where possible, make their own decisions and take control over their own lives. It can also provide a means of better informing people about their choices and the consequences of those choices. 66

Evidence 1. Alzheimer s Society (2009) Listening Well. http://www.alzheimers.org.uk/site/scripts/download_info.php?downloadid=379 2. Department of Health, Social Services and Public Safety (2010) Advocacy Research Summary Paper. http://www.dhsspsni.gov.uk/advocacy-research-summary-paper-of-advocacy-provisionoctober-2010.pdf 3. Developing Advocacy Services: A Policy Guide for Commissioners (2012). http://www.dhsspsni.gov.uk/developing-advocacy-services-a-guide-forcommissioners-may-2012.pdf 4. Horton,C. (2009) Creating a Stronger Information, Advice and Advocacy System for Older People. London: Joseph Rowntree Foundation. http://www.jrf.org.uk/system/files/information-systems-for-older-people-summary.pdf 5. Social Care Institute for Excellence (2009) At a glance 12: Implications for Advocacy Workers. http://www.scie.org.uk/publications/ataglance/ataglance12.asp 6. Wright, M (2006) A Voice That Wasn t Speaking: Older People Using Advocacy and Shaping its Development, Stoke-on-Trent, OPAAL UK (Older People s Advocacy Alliance). http://www.opaal.org.uk/libraries/local/1013/docs/resources/a%20voice%20that%20wasn't %20Speaking.pdf 7. Bamford Review (June 2007) Living Fuller Lives. http://www.dhsspsni.gov.uk/living_fuller_lives.pdf Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Delivery and Implementation Partners Independent Sector Voluntary and Community Sector 67

Quality Dimensions Person-centred - Services that are planned with individuals to meet their needs. Effectiveness - Advocacy schemes will ensure that the voice of the older person is heard in planning, delivery and evaluation of services. Efficiency - Less waste as services are designed according to the individual needs of the older person. Equity - An independent advocacy service will ensure that older people are not disadvantaged and that their views and opinions are central to decision making processes, thereby ensuring rights of redress and fairness. Performance Indicator 1. Each Trust has at least one Service Level Agreement with the voluntary or community sector to provide information, advice and advocacy services Data Source Health and Social Care Contracts Anticipated Performance Level All Trusts Date to be achieved by March 2015 (end of Year 1) 2. Increased awareness among older people of the role and function of advocacy Service user and carer feedback Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) 68

Standard 6: Independent Advocacy (Generic) Users of health and social care services and their carers should have access to independent advocacy as required Rationale People engage with health and social care services at times in their lives when they might be vulnerable or in need of support and / or guidance in relation to decisions about their health and wellbeing. For a whole raft of reasons (age, disability, mental health issues, gender, ethnic origin, sexual orientation, social exclusion, reputation, abuse and family breakdown and living away from home or in institutions), they may also feel discriminated against or simply excluded from major decisions affecting their health and wellbeing. It is at such times that independent advocacy can make a real difference because it gives people a voice; helps them access information so that they can make informed decisions and participate in their own care or treatment. Independent advocacy is also a means of securing and protecting a person s human rights; representing their interests; and ensuring that decisions are taken with due regard to a person s preferences or perspectives where, for whatever reason, they are unable to speak up for themselves. In strategic terms independent advocacy can contribute to increased social inclusion and justice; service improvements in health and wellbeing; reductions in inequalities across the health and social care sector; and enhanced safeguarding arrangements. Independent advocacy can be delivered in a number of different ways and people may need different types of advocacy at different times in their lives. The most common models are self/group advocacy; peer advocacy; citizen advocacy; and individual/issue-based advocacy (also known as professional advocacy). In this context, independence means structurally independent from statutory department or agency providing the service. The advocacy provider must be free from conflict of interest as possible as possible both in design and operation and must actively seek to reduce any conflicting interests. 69

Independent advocacy should be available throughout the care pathway and, in particular, should be available early in the process as this may prevent a crisis developing. An advocacy service should apply not just to service users but to their carers and families. There is currently a proposal to introduce a statutory right to an independent advocate in the proposed Mental Capacity Bill. Guidance on this right will be issued once the Bill has been finalised. To be effective users need to be aware of advocacy services. Therefore they need to be promoted through accurate and accessible information. Relevant health and social care staff should be aware of the benefits of independent advocacy and the particular importance of independence from service provision. Evidence 1. Alzheimer s Society (2009) Listening Well. Available at http://www.alzheimers.org.uk 2. Department of Health, Social Services and Public Safety (2010) Advocacy Research Summary Paper. Available at http://www.dhsspsni.gov.uk/advocacy-research-summary-paper-of-advocacy-provisionoctober-2010.pdf 3. Policy for Developing Advocacy Services: A Guide for Commissioners (2012) Available at http://www.dhsspsni.gov.uk/developing-advocacy-services-aguide-for-commissioners-may-2012.pdf 4. Horton, C (2009) Creating a Stronger Information, Advice and Advocacy System for Older People. London; Joseph Rowntree Foundation 5. Social Care Institute for Excellence (2009) At A Glance 12: Implications for Advocacy Workers available at http://www.scie.org.uk/publications/ataglance/ataglance12.asp 6. Seal, M. (2007) Patient Advocacy and Advance Care Planning in the Acute Hospital Setting Australian Journal of Advanced Nursing Vol 24, No 4, pp29-36 7. Wright, M. (2006) A Voice That Wasn t Speaking: Older People Using 70

Advocacy and Shaping it s Development, Stoke-on-Trent, OPAAL UK (Older People s Advocacy Alliance) 8. Bamford Review (2006). Review of Mental Health and Learning Disability (NI), Human Rights and Equality of Opportunity Available at www.dhsspsni.gov.uk/bamford 9. Knox, C. (2010) Policy Advocacy in Northern Ireland. University of Ulster, Jordanstown Responsibility for delivery / implementation Health and Social Care Board Public Health Agency Health and Social Care Trusts Delivery and Implementation Partners Local Commissioning Groups Primary Care Partnerships General Practitioners / Primary Care Working in partnership with the Voluntary and Community Sector Working in partnership with the Independent Sector Patient Client Council Quality Dimension Person-centred: Advocacy services can enable individuals to access information, express their views and wishes and make informed choices about their own health and well being. The service is geared to needs of the individual. The service user will receive a service that best meets their needs at a time, which evidence shows, to be effective and to have maximum impact. Safe: Advocacy services can safeguard users from abuse and exploitation by ensuring that their rights are upheld and their voice heard Effective: Advocacy can help prevent crises in a person s life which otherwise may result in an intervention that has greater resource implications. Advocacy can enhance capacity building at a community and individual level, which can ultimately reduce dependency on other health and social care services. An advocacy service can promote equality, social justice and inclusion of the most vulnerable and disadvantaged 71

Performance Indicator Data Source Anticipated Performance Level Date to be achieved by 1. To be determined. To be determined. 72

SECTION 4 HEALTH AND SOCIAL WELLBEING IMPROVEMENT. Overview of Health and Social Wellbeing Improvement Standards Introduction: Everyone aspires to be well and active as they grow older. This is based on health status and a feeling of value and self worth within society, local communities and families. Whilst older people are living longer, maintaining their health and wellbeing will determine both their quality of life, ability to remain independent and to contribute in a meaningful way to their community. Health and Social Care organisations have a key role to play in working with the community, independent statutory and voluntary sectors to promote the health and wellbeing of older people and to address the wider social determinants of health that result in many of the health inequalities that older people experience. The focus within health and social wellbeing improvement is to: advance health and wellbeing into older age; reduce the inequalities experienced by older people; promote the inclusion and full involvement of older people within society and their local communities; ensure older people are fully and meaningfully involved as equal partners in shaping policies, strategies, services and programmes that are designed to address their specific needs and circumstances; improve the provision, quality and safety of services and care to address the needs of older people as they age; identify those older people who are /or may become vulnerable as they get older; and maximise the contribution to the health and wellbeing of older people from all sectors and partners. 1. Healthy Ageing. All older people should have access to evidence based health and wellbeing advice, information, programmes and services that are tailored to address their specific and varied health and wellbeing needs across their life course. 2. Nutrition in Older People. All older people should be supported to achieve optimum nutritional health and maintain a healthy body weight. 73

3. Healthy Eating (Generic Standard): All HSC staff, as appropriate, should provide people with healthy eating support and guidance according to their needs. 4. Smoking (Generic Standard): All HSC staff, as appropriate, should advise people who smoke of the risks associated with smoking and signpost them to well-developed specialist smoking cessation services. 5. Alcohol (Generic Standard): All HSC staff, as appropriate, should provide support and advice on recommended levels of alcohol consumption. 6. Activity (Generic Standard): All HSC staff, as appropriate, should provide support and advice on recommended levels of physical activity. 7. Prevention of Falls. Older people should be informed of the factors which increase the risk of falling and be able to access interventions to reduce the risk. 8. Social Inclusion and Quality Of Life. All older people will be supported to maintain their mental health and well-being, quality of life and independence, as they grow older. Whilst each of the standards focus on a specific aspect of the health and wellbeing of older people it is important to highlight their interdependence one with the other and the need to apply the standards in a holistic manner. 74

Standard 7: Healthy Ageing All older people should have access to evidence based health and wellbeing advice, information, programmes and services that are tailored to address their specific and varied health and wellbeing needs across their life course. Rationale There is growing evidence to suggest that health improvement and the reduction of risk factors for disease in later life will have health benefits for the individual. Positive ageing which recognises the value and contribution of older people within communities is a key element in maintaining health and wellbeing. The active promotion of this before, and during, retirement has significant benefits in maintaining health, preventing disease and disability, ensuring independence and maintaining emotional and mental wellbeing. Older people are not a homogeneous group. Health improvement interventions need to reflect differences in gender, age, lifestyle, health status, sexual orientation, physical or learning disability, communication difficulties and the impact of cultural/religious beliefs. In addition the needs of older people will vary significantly over their life and services need to be dynamic and responsive to them. Given this diversity need, actions to address the health and wellbeing needs of older people should be multi-factorial in nature and delivered in collaboration with a wide range of partners from across the community, statutory, voluntary and private sectors. Health and social care organisations have a key role in ensuring needs are comprehensively assessed and individuals are referred to the most appropriate interventions to address their needs. Services should be provided in the most effective way possible and by those who are most appropriate to do so. Ongoing evaluation and monitoring of the changes that occur in the health and wellbeing of older people as a result of taking up these services should also be carried out to demonstrate effectiveness. 75

Health and wellbeing improvement services and programmes for older people should be tailored to address diversity, lifestyles and individual needs across the following areas: physical activity and exercise; healthy eating and nutrition; emotional and mental health and wellbeing; addressing life events such as bereavement and loss; reducing the risk of suicide; smoking cessation; sensible drinking; falls prevention, including bone health; protection from abuse, exploitation and neglect; oral health; preventing accidents and facilitating safer environments; feeling and being safe in the home and neighbourhood; sexual health; fuel poverty; benefit maximisation and income; access to services, new opportunities and support; and vaccinations and screening to help avoid illness and allow early diagnosis and intervention. Evidence 1. Allen, K and Glasby, J (2010) The Billion Dollar Question: Embedding Prevention in Older People s Services - 10 High Impact Changes. Discussion Paper. University of Birmingham, Health Services Management Centre. www.hsmc.bham.ac.uk 2. British Heart Foundation (2007) Active for Later Life. www.bhf.org.uk/publications/publications-search-results.aspx 3. Lewis, H. Fletcher, P. Hardy, B. Milne, A. & Waddington, E. (1999) Promoting Wellbeing: Developing a Preventive Approach with Older People. Leeds: Nuffield Institute for Health. 76

4. Lis, K. Reichert, M.,Cosack, A, Billings, J. & Brown, P. (Ed.) (2008). Evidence-Based Guidelines on Health Promotion for Older People. Austrian Red Cross, Vienna. http://www.healthproelderly.com/pdf/hpe-summary_final_online.pdf 5. National Health Service (2006) Inquiry into Mental Health and Well- Being. http://www.healthscotland.com/topics/stages/healthy-ageing/mental-health-later-life.aspx 6. National Institute for Health and Clinical Excellence (2008) Public Health Guidance: Occupational Therapy Interventions and Physical Activity Interventions to Promote the Mental Wellbeing of Older People in Primary Care and Residential Care. http://www.nice.org.uk/nicemedia/pdf/ph16guidance.pdf 7. Raynes, N. Beecham, J. and Clark, H. (2006) Evidence Submitted to the Older People's Inquiry into 'That Bit of Help'. Volume II Joseph Rowntree Foundation, York Publishing Services. http://www.jrf.org.uk/sites/files/jrf/9781859354612.pdf 8. Walters.R, Cattan.M, Speller.V, and Stuckelberger.A. (2000) Proven Strategies to Improve Older People's Health: a Eurolink Age Report for the European Commission. London: Eurolink Age. 9. Welsh Assembly Government (2006) National Service Framework for Older People in Wales. http://www.wales.nhs.uk/sites3/home.cfm?orgid=439 Responsibility for Delivery / Implementation HSCB PHA LCGs HSCTs GPs/Primary Care/ Community Pharmacy Delivery and Implementation Partners Independent Sector Voluntary and Community Sector 77

Quality Dimension Person-centred - Healthy ageing programmes must take cognisance of the needs of individual participants and the culture of their communities. Safety - Healthy ageing programmes delivered by trained staff will minimise the risk of side effects/injury. Timeliness - Access to earlier intervention to prevent need for care. Effectiveness - Programmes will evidence the outcomes of early intervention. By showing benefits to health, disease prevention, early diagnosis and assisting rehabilitation and re-ablement. Efficiency - Improved health and wellbeing will have positive effects on service delivery and efficiency, reducing pressure on health and social care services through prevention and aiding recovery after illness. Equity - Equitable access to programmes across geographies and Section 75 groupings. Agencies working to develop appropriate and accessible initiatives. Programmes targeted at greatest need to reduce health inequalities. Performance indicator 1. Board and PHA review of current services for older people to ensure that their health and wellbeing needs are identified and inform service change Data source Board/ PHA Joint Commissioning Plans and Report Anticipated performance level Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) and ongoing 78

2. Trusts review of their coordination of the development and delivery of multifaceted health and wellbeing programmes and services to address the wider health and wellbeing needs of older people 3. Trusts detailing the provision of appropriate assessment, advice and information on all aspects of health and wellbeing. Mechanisms should be in place to effectively signpost/refer older people to multisectoral services and support Trusts Older People s Service Development Plans and Reports on service provision, development and uptake Trusts reports on service provision and uptake Reports from the use of the Northern Ireland Single Assessment Tool Establish baseline Performance level set once baseline is established 60% 75% 90% March 2015 (end of Year 1) and ongoing March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 79

Standard 8: Nutrition In Older People All older people should be supported to achieve optimum nutritional health and to maintain a healthy body weight. Rationale Access to a healthy and well balanced diet is essential for maintaining health and wellbeing in older age. It is important that as people age they maintain a healthy diet and include a wide variety of foods in it. When combined with regular physical activity and exercise, a healthy diet will help older people remain healthy, manage their weight, maintain bone health, feel fitter and maintain their body s ability to resist disease and infection. As people age, changes in their bodies may result in lower energy (calorie) requirements. However, they still need the same vitamins and minerals as younger adults. It is important to ensure that whilst energy requirements may change it is essential to maintain a balanced intake across the four main food groups and that essential vitamins are maintained. As people get significantly older they may become malnourished due to poor diet or dehydration, social isolation, poor dental health, physical problems, poor mental health, confusion and the effect of medication. There is an increased risk of aspiration pneumonia in older people where oral health is compromised. Comprehensive nutritional assessment of the individual at this stage is essential to identify specific problems and their causes as early as possible (which may also include the possibility of abuse and neglect) and develop action to address these. Older people in care facilities may have poor levels of oral health which can impact on optimal nutrition levels. A diminished oral function has been linked to malnutrition, weight loss, and poor recovery from illness. 80

Therefore it is important to pay particular attention to the oral health of all older people within the care system and to reduce the possible impact this may have on their diet. Within health and social care settings it is essential to maintain good nutritional care by ensuring: nutritional screening takes place on admission to services; older people have meals that are appetising and appropriate; mealtimes are not interrupted by other routine activities; there are sufficient numbers of staff allocated to support those who need help and to improve food intake where necessary; environments are conducive to eating; older people have access to sufficient sunlight to protect their vitamin D levels; and post menopausal women have adequate calcium intake. adequate levels of fluid intake are maintained. Older people s preferences and their dietary and cultural requirements must be taken into account. Evidence shows that staff need the skills to provide help, support and be able to communicate effectively to older people especially if they have particular needs due to dementia and/or communication difficulties. Health and social care organisations should provide information and support to help carers address the diet and nutritional needs of those for whom they are caring. Evidence 1. Department of Health, Social Services and Public Safety (2011). Promoting Good Nutrition A Strategy for good Nutritional Care for Adults in all Care Settings in Northern Ireland, 2011 2016. http://www.dhsspsni.gov.uk/promoting_good_nutrition.pdf 2. Age Concern (2006) Hungry to be Heard. London: Age Concern. http://www.scie.org.uk/publications/guides/guide15/files/hungrytobeheard.pdf 81

3. Age UK (2010) Still Hungry to be Heard. London: Age UK. http://www.ageuk.org.uk/london/news--campaigns/still-hungry-to-be-heard/ 4. Bradley, M. and Porter, N. Oral Health Guidelines for Older Adults in Care Homes in Northern Ireland. www.gain-ni.org 5 British Association for Parenteral and Enteral Nutrition (2006) Malnutrition amongst Older People in the Community: Policy Recommendations for Change. http://www.europeannutrition.org/index.php/events/malnutrition_among_older_people_in_the_community_polic y_recommendations_for change 6. Caroline Walker Trust (2004) Eating Well for Older People: Practical & Nutritional Guidelines for Older People in Residential and Community Care. www.cwt.org.uk 7. Department of Health, Social Services and Public Safety (2007) Oral Health Strategy for Northern Ireland. http://www.dhsspsni.gov.uk/2007_06_25_ohs_full_7.0.pdf 8. Department of Health, Social Services and Public Safety (2008). Nursing Homes: Minimum Standards. http://www.dhsspsni.gov.uk/care_standards_-_nursing_homes.pdf 9. Department of Health, Social Services and Public Safety (2011). Residential Homes: Minimum Standards. http://www.dhsspsni.gov.uk/care standards residential-care -homes. pdf 10. Department of Health, Social Services and Public Safety (2007) Get Your 10 a Day! The Nursing Care Standards for Patient Food in Hospitals. http://www.dhsspsni.gov.uk/food_standards-10_a_day.pdf 11. Department of Health (2005). Meeting the Challenges of Oral Health for Older People, A Strategic Review. London: Department of Health. http://www.dh.gov.uk 12. Department of Health (2009) Delivering Better Oral Health An Evidence-based Toolkit for Prevention. Second Edition. London: Department of Health. http://www.dh.gov.uk 82

13. Food Standards Agency (2011) The Eatwell Plate http://www.nhs.uk/livewell/goodfood/pages/eatwell-plate.aspx 14. National Institute for Clinical Excellence (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. http://www.nice.org.uk/cg32 15. Scottish Intercollegiate Guidelines Network (2003) Management of Osteoporosis. Guideline 71. http://www.sign.ac.uk/pdf/sign71.pdf 16. Walsh, K. (2010) Healthy Ageing in Rural Communities. Dublin: Centre for Ageing Research and Development in Ireland. http://www.cardi.ie/userfiles/healthy%20ageing%20(web%20low%20res).pdf Responsibility for Delivery / Implementation HSCB PHA LCGs HSCTs GPs/Primary Care/ Community Pharmacy Quality Dimensions Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Person-centred - Individualised person-centred approach to enable client to achieve optimum nutritional health acknowledging cultural preferences. Safety - Food safety including appropriate food handling, cooking methods, minimising risk of food brought into care settings. Individual swallowing assessment. Timeliness - Dental and nutrition assessment on referral, admission or review and addressed through subsequent care plan. Effectiveness - Malnutrition reduction, optimum nutrition and oral health is achieved through effective training, and communication. Efficiency- Optimum nutrition will reduce longer term ill health, readmission, due to delayed recovery post-surgery and wound healing and prevention of pressure sores and falls. 83

Equity - A focus is required across all settings regardless of place of residence/care setting, individual choices/circumstances. Performance Indicators 1. The Board/PHA review of the current services addressing the nutritional needs of older people and ensure interventions are in place to promote healthy eating and identify and address individuals at risk of malnutrition 2. Trusts reports showing that older people within their care have access to and are adequately supported to maintain a healthy and well balanced diet Data Source Health and Social Care Board s/ Public Health Agency s Joint Commissioning Plan and Reports Trust Report Regulation and Quality Improvement Authority Inspection Reports Anticipated Performance Level Establish baseline Performance level set once baseline is established All Trusts Date to be achieved by March 2015(end of Year 1) and ongoing March 2015(end of Year 1) and ongoing 84

3. Number of older people and, where appropriate their carers access a comprehensive range of health information, advice and support services/ programmes to maintain and improve their nutritional and oral health Trust Older People s Service Delivery Plans Establish baseline Performance level set once baseline is established March 2015(end of Year 1) and ongoing 4. Number of older people in acute care, residential or nursing homes or in receipt of a community care package who have access to oral health screening and appropriate dental treatment and care. Regulation and Quality Improvement Authority Inspection Reports on the GAIN Guidelines Reports from Community Dental Services Establish baseline Performance level set once baseline is established March 2015(end of Year 1) and ongoing 85

Standard 9: Healthy Eating (Generic) All HSC staff, as appropriate, should provide people with healthy eating support and guidance appropriate to their needs. Rationale Reducing fat and salt in the diet and increasing fruit and vegetable consumption is associated with a reduction in the risk of cardiovascular disease and hypertension. Having a well balanced and nutritious diet will also help prevent many diseases which are linked to being overweight and obese such as high blood pressure, heart problems, risk of stroke, some cancers and Type 2 Diabetes. In addition, an improved diet can also contribute to an improvement in an individual s mental health and wellbeing. Evidence 1. WHO Global Strategy on Diet, Physical Activity and Health http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf 2. Fit Futures http://www.dhsspsni.gov.uk/ifh-fitfutures.pdf 3. Scientific Advisory Committee on Nutrition recommendations on healthy eating for the general population http://www.sacn.gov.uk/reports/ 4. DHSSPS Framework for Preventing and Addressing Overweight and Obesity in Northern Ireland (2012-2022) http://www.dhsspsni.gov.uk/showconsultations?txtid=44910 Responsibility for delivery / implementation Health and Social Care Board Public Health Agency HSC Trusts Delivery and Implementation Partners Primary Care team, inclusive of social care 86

Quality Dimension Effective: All stakeholders should promote a consistent nutrition message by using the Eat Well getting the balance right plate model. Training and education should be available for child carers / group care workers. Person-centred: Schools / hospitals / residential care and nursing homes should be supported in the implementation of nutrition standards. Support and advice to develop skills for healthy eating in a range of settings should be available. Performance Indicator 1. Percentage of people eating the recommended 5 portions of fruit or vegetables each day. Data source To be determined Anticipated Performance Level Baseline for 2011/12 = 32% overall, 26% for males and 36% for females Target: maintain or at best increase percentage by 1% year on year Date to be achieved by 87

Standard 10: Smoking (Generic) All Health and Social Care staff, as appropriate, should advise people who smoke of the risks associated with smoking and sign-post them to well-developed specialist smoking cessation services. Rationale Smoking is a major risk factor for a number of chronic diseases including a range of cancers, coronary heart disease, strokes and other diseases of the circulatory system. Its effects are related to the amount of tobacco smoked daily and the duration of smoking. A number of specialist smoking cessation services have been commissioned in a range of settings across Northern Ireland. These services offer counselling and support in addition to the use of pharmacotherapy by trained specialist advisors. Evidence 1. Tobacco Control Strategy for Northern Ireland 2012-2022 http://www.dhsspsni.gov.uk/showconsultations?txtid=46925 2. NICE produced guidance on brief interventions and referral for smoking cessation in primary care and other settings in March 2006, which represents best practice http://www.nice.org.uk/guidance/ph1 3. NICE guidance on Smoking Cessation Services, in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities, February 2008 http://www.nice.org.uk/guidance/ph10 Responsibility for Delivery / Implementation Health and Social Care Board Public Health Agency HSC Trusts Primary Care Community Pharmacists Delivery and Implementation Partners DHSSPS Families & Carers Voluntary, education, youth, and community organisations 88

Quality Dimension Effective - Brief Intervention Training for Health and Social Care Staff will ensure clients receive consistent and timely advice on smoking cessation. Specialist smoking cessation services will be delivered to regional quality standards ensuring equitable service provision. People who are ready to stop smoking should be able to access specialist smoking cessation services in a choice of settings. Performance Indicator 1.Number of people who are accessing Stop Smoking Services Data source ELITE (PHA Stop Smoking Services Report) Anticipated Performance Level Baseline 2011/12 = 39,204. 4 % year on year increase Date to be achieved by March 2014 March 2015 March 2016 2.Proportion of the smoking population who are accessing Stop Smoking Services ELITE Baseline 2011/12 =10.8%. NICE guidance and the ten year tobacco strategy call for a target of over 5% of the smoking population to be reached, hence target should be to maintain at >= 5% March 2014 March 2015 March 2016 89

3.Number of people using stop smoking services who have quit at 4 weeks and 52 weeks ELITE Baseline 2011/12 = 20,299 for those quit at 4 weeks and 5,889 for those quit at 52 weeks. 4% year on year increase from 11/12 baseline (20,299 4 weeks, 5,889 52 weeks) March 2014 March 2015 March 2016 90

Standard 11: Alcohol (Generic) All HSC staff, as appropriate, should provide support and advice on appropriate levels of alcohol consumption. Rationale Excessive alcohol consumption is associated with many diseases such as cancers (oesophagus, liver etc), cirrhosis of the liver and pancreatitis. There are also direct effects of alcohol and an increased association with injuries and violence. Excessive alcohol consumption can affect the cardiovascular system, and is associated with high blood pressure, abnormal heart rhythms, cardiomyopathy and haemorrhagic stroke. Evidence 1. SIGN: The Management of harmful drinking and alcohol dependence in Primary Care http://www.sign.ac.uk/pdf/sign74.pdf 2. New Strategic Direction for Alcohol and Drugs Phase 2 (2011 2016) http://www.dhsspsni.gov.uk/new_strategic_direction_for_alcohol_and_drugs_phase_2 2011-2016_ Responsibility for Delivery/ Implementation HSC Board Public Health Agency HSC Trusts Delivery and Implementation Partners Primary Care team, inclusive of social care Quality Dimensions Effective - Appropriate alcohol brief intervention training should be provided for Health and Social Care Staff to ensure clients receive consistent and timely advice. 91

Performance Indicator 1.Percentage of people who receive screening in primary care settings in relation to their alcohol consumption Data source Northern Ireland Local Enhanced Service for Alcohol Anticipated Performance Level Establish baseline. Performance level to be agreed thereafter. Date to be achieved by March 2014. March 2015. 92

Standard 12: Activity (Generic) All HSC staff, as appropriate, should provide support and advice on appropriate levels of physical activity. Rationale The National Institute for Health and Clinical Excellence (NICE) has fully endorsed the importance of physical activity as a means of promoting good health and preventing disease. Lack of physical activity is associated with an increase in the risk of coronary heart disease. The recently reviewed and updated UK Physical Activity Guidelines, supported by all four CMO s, provide advice and guidance on the recommended levels of physical activity throughout the life course. The report also presents the first time guidelines have been produced in the UK for early years (under fives) as well as sedentary behaviour, for which there is now evidence that this is an independent risk factor for ill health. Responsibility for delivery / implementation Health and Social Care Board Public Health Agency HSC Trusts Delivery and Implementation Partners Primary Care team, inclusive of social care Quality Dimension Effective: Appropriate physical activity brief intervention training should be provided for Health and Social Care Staff to ensure clients receive consistent and timely advice. 93

Performance Indicator Data source Anticipated Performance Level Date to be achieved by 1. Percentage of people meeting the recommended level of physical activity per week. Northern Ireland Health Survey New physical activity guidelines were launched in 2011 and as such a new suite of questions to establish the percentage of people meeting the recommended level of physical activity per week has been integrated within the 2012/13 Northern Ireland Health Survey. It is anticipated these new baseline results will be available in Nov/ Dec 2013. March 2014 Performance level to be agreed thereafter 94

Standard 13: Prevention of Falls Older people should be informed of the factors which increase risk of fragility fractures as a result of osteoporosis or reduced bone strength. and be able to access interventions to reduce the risk. Rationale Falls are a major cause of disability and the leading cause of death due to injury, in people aged over 75. Studies have shown that, in the general population aged over 65, one third of people will have a fall each year. People aged over 75 have an even higher risk of falling as a result of medical conditions, environment, medication, drugs and alcohol. Osteoporosis and bone fragility increases morbidity resulting from falling. In institutional care over 50% of individuals will have a fall every year and this increases to 60-70% of those who have previously fallen. It is estimated that 40-60% of falls lead to injuries. In addition to injuries one third of older people, after a fall, develop a fear of further falling. Those with a fear of further falling have also been shown to have an increased risk of falling, reduced activities of daily living, lower SF36 scores, social isolation and depression and increased admission to institutional care. Research studies show that the use of evidence-based, multi-factorial interventions can reduce falls by 15-30%. Whilst the standard focuses specifically on access to specific falls prevention services it is important to recognise the wider health improvement context for falls prevention reflected in Standard 4 on the Promotion of Health and Wellbeing which addresses the need to: enhance physical activity levels; promote a healthy and balanced diet that includes adequate intake of calcium to maintain bone health; reduce smoking; reduce alcohol intake; manage the intake of medicines; ensure access to regular sight and eye checks; and reduce the risk of falls by ensuring safe environments in both the home and community/neighbourhood settings. 95

Evidence 1. American Geriatric Society, British Geriatric Society, and American Academy of Orthopaedic Surgeons. (2001). Guidelines for the Prevention of Falls in Older People. Canadian Patient Safety Institute. 2. Close,J. et al. (1999) Prevention of Falls in the Elderly Trial (PROFET): a Randomised Controlled Trial. Lancet; 353: 93-97. 3.Department of Health (2001). National Service Framework for Older People London: Department of Health. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidanc e/dh_4003066 4.Greater Glasgow NHS Strategy for Osteoporosis and Falls Prevention (2006) Glasgow: NHS Greater Glasgow and Clyde Health Board. 5. National Institute of Clinical Excellence (2002) Falls: the Assessment and Prevention of Falls in Older People. http://www.nice.org.uk/nicemedia/pdf/cg021fullguideline.pdf 6. National Patient Safety Agency. (2007) Slips, Trips and Falls in Hospital. The Third Report from the Patient Safety Observatory. London: National Patient Safety Agency. www.nrls.npsa.nhs.uk/easysiteweb/getresource.axd?assetid=60129... 7. Patient Safety First (2009) Reducing Harm from Falls Version 1. http://www.patientsafetyfirst.nhs.uk 8. Scottish Intercollegiate Guidelines Network (2003) Management of Osteoporosis. Guideline 71. http://www.sign.ac.uk/pdf/sign71.pdf Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care/ Community Pharmacy Northern Ireland Ambulance Service Delivery and Implementation Partners Independent Sector Voluntary and Community Sector 96

Quality Dimensions Person-centred - People having falls will have local services available when they are most needed. Safety - Evidence based interventions reduce the risk of falls. Timeliness - Early interventions reduce the risk of falling and recurrent more severe falls. Effectiveness - Interventions are based on evidence of effectiveness which reduce falls by 15-30%. Efficiency - Early use of primary and secondary prevention interventions will avoid the need for more expensive health and social care following a fall which leads to injury and loss of confidence. Performance Indicator 1. Health and Social Care Board s/public Health Agency s review of the current provision of falls prevention services to ensure the provision of comprehensive, evidence based falls prevention services for all older people 2. Trust Report detailing the provision of coordinated Falls Services that increase awareness of the ways to prevent and reduce the risk of falling, provide falls prevention programmes that have reduced the risk Data Source Health and Social Care Board/ Public Health Agency Joint Commissioning Plan and Report Trust Service Delivery plans and reports Reports from the use of the Northern Ireland Single Assessment Tool Anticipated Performance Level All Trusts Establish baseline Performance level set once baseline is established Date to be achieved by March 2015(end of Year 1) and ongoing March 2015(end of Year 1) and ongoing 97

of older people falling including strength and balance training, and offer services to reduce the impact of falls. 3. Trusts will ensure the provision of coordinated, community based health and wellbeing services and programmes that seek to reduce the risk of falling by increasing physical activity, maintaining a healthy diet, ensuring regular vision checks, stopping smoking, reducing alcohol intake, maintaining safe homes and neighbourhood environments 4. Older people in contact with health and social care services are routinely asked whether they have fallen in the past year, have their risk of falling assessed and provided with appropriate advice, support and signposting to services to address their specific needs Trust Service Delivery plans and reports Service user / carer feedback Establish baseline Performance level set once baseline is established 60% 75% 90% March 2015(end of Year 1) and ongoing March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 98

5. All nursing homes which have been contracted by Health and Social Care Trusts will have in place actions to reduce the risk and impact of falling by residents. RQIA Monitoring Reports Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) and ongoing 6. All older people, who have a fall, and call for an ambulance, are placed on an appropriate pathway for assessment and intervention Ambulance service reports Trust audit on outcomes of all those referred by Ambulance Services Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) and ongoing 99

Standard 14: Social Inclusion and Quality of Life All older people will be supported to maintain their mental health and wellbeing, quality of life and independence as they grow older. Rationale Social, emotional and mental health are key elements in the overall health and wellbeing of older people. Feeling valued and being recognised within society is of great importance to everyone. The needs and circumstances of people vary significantly throughout their life. As people grow older personal health, social factors and changes in family relationships can impact on the well being of the individual. Addressing the impact of social isolation, loneliness and associated mental health issues will have significant impact on the health and well being of older people. It has been shown that Health and Social Care organisations have a key role in identifying the wider mental health and social well being needs of an older person and their carers as they move through their life course. They have a central role in ensuring coordinated and early action across a wide range of community, statutory and voluntary services to address the needs of individuals related to: mental wellbeing; the loss of a partner, relative or friend; having access to adequate levels of income; fuel poverty; feeling safe and secure in their own home and neighbourhood and reducing the fear of crime; having access to new, meaningful opportunities and experiences such as education and learning, social interaction etc; accessing the right type of services at the right time; maintaining regular social contact and reducing the impact of social isolation; protection from abuse; exploitation and neglect; dealing with decreasing mobility and the ability to undertake everyday living tasks; dealing with increasing sensory impairment and other long term conditions; access to appropriate housing; access to services; 100

access to transport; and the ability to maintain and improve personal health and wellbeing. Evidence 1. Age UK (2006) UK Inquiry into Mental Health and Well-being in Later Life. London: Age UK. http://www.ageuk.org.uk 2. Allen, Kerry and Glasby, Jon (2010) The Billion Dollar Question: Embedding Prevention in Older People s Services - 10 High Impact Changes. Discussion Paper. University of Birmingham, Health Services Management Centre. http://www.hsmc.bham.ac.uk 3. Breen, C. (2011) Focus on Ageing Strategies. Dublin: Centre for Ageing Research and Development in Ireland. 4. Department of Health, Social Services and Public Safety (2005) A Healthier Future: 20 year Vision for Health and Wellbeing in NI 2005-2025 Regional Strategy. http://www.dhsspsni.gov.uk/healthyfuture-main.pdf 5. Department of Health, Social Services and Public Safety (2002) Investing for Health Strategy. http://www.dhsspsni.gov.uk/index/phealth/php/ifh.htm 6. European Commission (2008) Evidence Based Guidelines on Health Promotion for Older People. http://www.healthproelderly.com/pdf/hpe-guidelines_online.pdf 7. Graves, C. et al (2009) Effects of Creative and Social Activity on the Health and Wellbeing of Socially Isolated Older People: Outcomes from a Multi-dimensional Study, Journal of the Royal Society for the Promotion of Health, 126(3), 134-142). 8. Lewis, H. Fletcher, P. Hardy,B. Milne,A. and Waddington,E. (1999) Promoting Well-being: Developing a Preventive Approach with Older People. Leeds: Nuffield Institute for Health. http://www.housingcare.org/downloads/kbase/2333.pdf 9. Marmot, M. (2010) Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England, Post 2010. http://www.ucl.ac.uk/gheg/marmotreview 101

10. Office of First Minister and Deputy First Minister (2005). Ageing in an Inclusive Society: Promoting the Social Inclusion of Older People. http://www.ofmdfmni.gov.uk/ageingreport-2.pdf 11. Office of the Deputy Prime Minister (2006) A Sure Start to Later Life: Ending Inequalities for Older People a Social Exclusion Unit Final Report. www.dh.gov.uk 12. Raynes, N. Clark,H. Beecham, J. (2006) The Report of the Older Peoples Inquiry into That Bit of Help. York : Joseph Rowntree Foundation. www.jrf.org.uk 13. Walters,R. Cattan,M. Spellar,V. and Stuckelberger,A. (2000) Proven Strategies to Improve Older People s Health: a Eurolink Age Report for the European Commission. www.dh.gov.uk 14. Joseph Rowntree Foundation, Centre for Policy on Ageing (2011). How can Local Authorities with less Money Support Better Outcomes for Older People Solutions, Lessons for Policy and Practice. www.jrf.org.uk 15. Welsh Assembly Government (2006) National Service Framework for Older People in Wales. http://www.wales.nhs.uk/sites3/home.cfm?orgid=439 Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care/ Community Pharmacy Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Northern Ireland Housing Executive 102

Quality Dimensions Person-centred - The needs of individuals should be identified and used to inform and shape service response. Safety - Services need to ensure that older people feel and remain safe and need to be provided by adequately trained staff. Timeliness - Services need to be adequately resourced to respond in a timely way to address the changing needs of older people across the life course. Efficiency - Addressing the wider social needs of older people in an appropriate and timely manner will reduce the need for health and care services in later life. Effectiveness - Access to services to address the wider social determinants of health will impact significantly on health and wellbeing and the quality of life of older people. Equity - Older people should have easy access to services and support to address their particular needs and circumstances as a basic human right. 103

Performance Indicator 1. Health and Social Care Board s/public Health Agency s review of the current provision of services to address the mental health and social wellbeing needs of older people and ensure effective multi-sectoral approaches are developed and maintained to address the wider social determinants and impact of social isolation 2. Health and Social Care Trusts coordination, development and delivery of multifaceted services and programmes with local partners to address the wider mental health and social wellbeing needs of older people and their carers Data Source Health and Social Care Board/ Public Health Agency Joint Commissioning Plan and Report Reports from the NINIS/ Investing for Health and Wellbeing Indicators Trusts Older People s Service Delivery Plans and reports Anticipated Performance Level Date to be achieved by All Trusts March 2015 (end of Year 1) and ongoing All Trusts March 2015 (end of Year 1) and ongoing 104

Performance Indicator 3. All older people in contact with services have access to appropriate assessment of their wider health and well-being needs and signposting to further help and support as required Data Source Trust reports to evidence service provision and uptake. Reports from the use of the Northern Ireland Single Assessment Tool. Anticipated Performance Level 60% 75% 100% Date to be achieved by March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 105

SECTION 5 SAFEGUARDING Overview of Safeguarding Standards Introduction: There is a growing recognition of the incidence of the abuse of older people, at a local, national and international level. These standards set out what needs to happen to safeguard older people and what they, and their carers, can expect from health and social care organisations should it become known that an older person is being harmed through abuse, exploitation or neglect. 1. Raising Public Awareness: Health and social care organisations must work together to prevent the abuse or exploitation of people by raising public awareness and to develop a clear message that such abuse is not acceptable and will not be tolerated. 2. Accessing Services to Safeguard Older People: Health and social care organisations should work with older people, their carers and relevant others to recognise situations of abuse or exploitation and to access services to safeguard vulnerable people. 3. Responding to Older People who are at Risk: Health and social care organisations, which receive a report that an individual has been or may be experiencing abuse or neglect, will respond in a positive, timely and proactive manner. 4. Development of Protection Plans: Health and social care organisations will work in partnership with service users, their carers and/or representatives and other relevant agencies so that any Protection Plan is tailored to meet the needs of the older person. 5. Safeguarding People (Generic Standard): All HSC staff should ensure that people of all ages are safeguarded from harm through abuse, exploitation or neglect. 106

Standard 15: Raising Public Awareness Health and social care organisations must work together to prevent the abuse of exploitation of older people by raising awareness and developing a clear message that such abuse is unacceptable and will not be tolerated. Rationale Older people are not a homogenous group. Many will live rich and fulfilling lives with appropriate support from family members, friends and neighbours, and will never require intervention from health and social care services. However, a minority of older people may need outside support if, due to a change in their circumstances, increased frailty or vulnerability, or if they are no longer able to protect themselves from situations or relationships that may result in them being at risk of exploitation or abuse. Research studies have used different definitions and measures of abuse, and have concentrated on different groups or populations of older people. These studies indicate that every year between 3% and 6% of older people are subject to abuse. Therefore in Northern Ireland, this would mean that in 2009 between 7634 and 15269 older people were victims of abuse. However, only a small proportion of the abuse of older people is brought to the attention of safeguarding services. Evidence 1. Cooper, C., et al (2008) The Prevalence of Elder Abuse and Neglect: a Systematic Review. Age and Ageing, 37; pp.151 160. 2. Department of Health (2000) No Secrets: Guidance on Developing and Implementing Multi-agency Policies and Procedures to Protect Vulnerable Adults from Abuse. London: Department of Health. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguid ance/dh_4008486 3. Department of Health (2002) World Health Organisation: The Toronto Declaration on the Global Prevention of Elder Abuse. London: Department of Health. http://www.globalaging.org/elderrights/world/2007/torontodecla.pdf 107

4. Department of Health, Social Services and Public Safety (2010). Adult Safeguarding in Northern Ireland: Regional and Local Partnership Arrangements. Belfast: Department of Health, Social Services and Public Safety. http://www.hscboard.hscni.net/publications/legacyboardsregional Adult protection Policy and Procedural Guidance 2006 5. Northern Health and Social Services Board (2006) Safeguarding Vulnerable Adults: Regional Adult Protection Policy and Procedural Guidance. http://www.dhsspsni.gov.uk/safeguarding_vulnerable_adults-resourcelibrary - Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Police Service Northern Ireland RQIA Quality Dimensions Safety - Increases the ability of older people to reduce the likelihood of abuse and increase awareness of abuse of older people and sources of support in relation to safeguarding vulnerable older people. Timeliness - Facilitates the early identification of those people most at risk of abuse or exploitation. Effectiveness - Assists organisations, groups and older people themselves to identify potential abuse. 108

Performance Indicator 1. Northern Ireland Adult Safeguarding Partnership s (NIASP) Strategic Plan and Annual Action Plans to include a prevention plan 2. Local Adult Safeguarding Partnerships (LASP) Safeguarding Plan and annual Action Plans to include a local prevention plan Data Source NIASP Strategic Plan 2012 2017 NIASP Annual Action Plans LASP Safeguarding Plans 2012 2017 Local Prevention Plans Anticipated Performance Level Date to be achieved by All Trusts March 2015 (end of Year 1) and ongoing All Trusts March 2015 (end of Year 1) and ongoing March 2015 (end of Year 1) and ongoing 3. Delivery of at least one Peer Educator training programme for older people in each Trust area Training programme report All Trusts March 2016 (end of Year 2) and ongoing 109

Standard 16: Accessing Services to Safeguard Older People Health and social care professionals should work with older people, their carers and relevant others to recognise situations of abuse or exploitation and to access services to safeguard vulnerable people. Rationale When it is suspected that an individual is or has been subject to abuse or exploitation, it is crucial that they know how to access the support and services they require in order to protect themselves. Abuse is a difficult topic for some older people to discuss and they may be reluctant to disclose that they have been subject to abuse or exploitation. There are many reasons for this reluctance and older people may experience feelings of shame that the abuse has occurred, anxiety about their future, or feel a responsibility towards the perpetrator. The abusive behaviour may also be longstanding, and perceived to be part of family culture and history. Evidence 1. Department of Health (2000) No Secrets: Guidance on Developing and Implementing Multi-agency Policies and Procedures to Protect Vulnerable Adults from Abuse. London: Department of Health. http://www.dh.gov.uk/en/.../publicationspolicyandguidance/dh_4008486 2. Department of Health, Social Services and Public Safety (2010). Adult Safeguarding in Northern Ireland: Regional and Local Partnership Arrangements. Belfast: Department of Health, Social Services and Public Safety. http://www.dhsspsni.gov.uk/reforming_ni_adult_protection_infrastructure.pdf 3. Department of Health, Social Services and Public Safety (2003). Good Practice in Consent. Belfast: Department of Health, Social Services and Public Safety. http://www.dhsspsni.gov.uk/hssmd07-03.pdf 4. Donohue, W. et al (2008) A Social Capital Approach to the Prevention of Elder Mistreatment Journal Of Elder Abuse and Neglect 20(1) pp.1 23. 110

5. House of Commons Health Select Committee Elder Abuse (2004) First Report of Session 2003/04 Volume 1, Report together with Formal Minutes. HC111 1. London: The Stationery Office. http://www.elderabuse.org.uk/documents/health%20select%20commitee%20report% 20-%20Elder%20Abuse%20-%202004.pdf 6. World Health Organisation (2002) Missing Voices: Views of Older Persons on Elder Abuse. Geneva: World Health Organisation. 7. United Nations (1948) Universal Declaration of Human Rights. http://www.un.org/rights/50/decla.htm Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care RQIA Quality Dimensions Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Police Service Northern Ireland Person-centred - Increases the ability of older people to reduce the likelihood of abuse and empower older people to make informed decisions in relation to protecting themselves from abuse or exploitation. Safety - Increases awareness of abuse of older people and sources of support in relation to safeguarding vulnerable older people. It will also increase awareness of abuse and sources of support to safeguard older people amongst care givers. Efficiency - Facilitates the targeting of support services and systems to those most at risk of abuse or exploitation. 111

Performance Indicator 1. NIASP Strategy and associated Annual Action Plans will include the development, implementation and review of standardised regional thresholds for access to adult safeguarding services, to improve consistency of screening and decision-making 2. Each LASP Safeguarding Plan and associated annual Action Plans will include clear signposting of services and standardised regional thresholds for access to adult safeguarding services, to improve consistency of screening and decision-making 3. Each provider organisation ensures that information on how to access safeguarding services is available to service users and their carers Data Source NIASP Strategic Plans NIASP Annual Action Plans LASP Safeguarding Plans LASP Annual Action Plans Service User and Carer Feedback Anticipated Performance Level Date to be achieved by All Trusts March 2015 (end of Year 1) and ongoing March 2015 (end of Year 1) and ongoing All Trusts March 2015 (end of Year 1) and ongoing March 2015 (end of Year 1) and ongoing 80% March 2015 (end of Year 1) and ongoing 112

4. Each provider organisation ensures that all staff members receive appropriate training on how to recognise abuse and access safeguarding services 5. Establishment of at least one Peer Advocacy service to support people through the process of disclosure of abuse, exploitation or neglect in each Trust area 6. Number of service users where potential abuse is identified at initial assessment as % of referrals to safeguarding services Contracts / Service Level Agreements Monitoring reports NIASP Training Framework 80% March 2015 (end of Year 1) and ongoing Trust Report All Trusts March 2016 (end of Year 2) and ongoing Northern Ireland Single Assessment Tool returns Delegated Statutory Functions Reports Establish baseline Performance level set once baseline is established March 2016 (end of Year 2) and ongoing 113

Standard 17: Responding to Older People who are at Risk Health and social care organisations that receive a report that an individual has been or may be experiencing abuse, or neglect will respond in a positive, timely and proactive manner. Rationale It has been shown that when there has been an alert that an individual is at risk of or has experienced abuse, it is vital that the information is responded to as quickly as possible. People will require varying levels of support through this process, depending on the nature of the abuse, their level of independence, their health status and their capacity to make informed decisions. The needs, wishes and feelings of the individual must be considered throughout the response process. Responses to abuse must be proportionate, in the interests of the individual at risk or who has been abused, and focussed on ensuring the safety and protection from abuse or exploitation of that person. People who are at risk or have experienced abuse should be: provided with information about all relevant options available to them; encouraged and assisted to make their own decisions; respected and given the choice to refuse services if competent to make that decision. Even when it has been determined or observed that the person cannot make their own decisions, every effort must be made to ensure their views are taken into account. While the lead role in any formal investigation will rest with the local Health and Social Care Trust, every organisation or agency providing care and/or support to people at risk of harm should have an identified lead person or manager for adult safeguarding. 114

Evidence 1. Association of Directors of Social Services (2005) Safeguarding Adults: National Framework of Standards for Good Practice and Outcomes in Adult Protection Work. London: Association of Directors of Social Services. http://www.adass.org.uk/images/stories/publications/guidance/safeguarding. 2. Department of Health (2000) No Secrets: Guidance on Developing and Implementing Multi-agency Policies and Procedures to Protect Vulnerable Adults from Abuse. London: Department of Health. http://www.dh.gov.uk/en/.../publicationspolicyandguidance/dh_ 3. Department of Health and Criminal Justice System (2009) Safeguarding Adults: Report on the Consultation on the Review of No Secrets. London: Department of Health. http://www.nmc-uk.org 4. Department of Health, Social Services and Public Safety (2010). Adult Safeguarding in Northern Ireland: Regional and Local Partnership Arrangements. Belfast: Department of Health, Social Services and Public Safety. http://www.dhsspsni.gov.uk/asva-_march_2010. 5. Department of Health, Social Services and Public Safety (2003). Good Practice in Consent. Belfast: Department of Health, Social Services and Public Safety. http://www.dhsspsni.gov.uk/hssmd07-03. 6.Donohue W., et al (2008) A Social Capital Approach to the Prevention of Elder Mistreatment Journal Of Elder Abuse and Neglect 20 (1), pp.1 23. 7. House of Commons Health Select Committee Elder Abuse (2004) First Report of Session 2003/04 Volume 1, Report together with Formal Minutes. HC111 1. London: The Stationery Office http://www.elderabuse.org.uk/documents/health select committee report - Elder Abuse 2004. 8. Northern Health and Social Services Board (2006) Safeguarding Vulnerable Adults: Regional Adult Protection Policy and Procedural Guidance. http://www.nhssb.ni.nhs.uk/publications/social_services/safeguarding_vulnerable_ Adults. 115

9. World Health Organisation (2002) Missing Voices: Views of Older Persons on Elder Abuse. Geneva: World Health Organisation http://www.un.org/en/documents/udhr/ 10. United Nations (1948) Universal Declaration of Human Rights www.un.org Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care RQIA Quality Dimensions Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Police Service Northern Ireland Person-centred - Ensures that all responses to abuse or exploitation will be tailored to meet individual needs. Older people will be offered choice and options to keep themselves safe. Safety - Ensures that the rights of all parties, including the older person, their family, and carers are maintained. Timeliness - Ensures that initial responses to abuse are provided within the appropriate timescales contained within relevant regional policy and guidance. Equity - Ensures that all older people will receive an appropriate response to an allegation or disclosure of abuse, regardless of the setting they are in or their perceived capacity. Performance Indicator 1. NIASP will ensure that all regional adult safeguarding procedures include timescales for responding to allegations of abuse Data Source Regional Adult Safeguarding Policy and Procedures and Protocol for Joint Investigations Report Anticipated Performance Level Date to be achieved by All Trusts March 2015 (end of Year 1) and ongoing 116

2. Local Adult Safeguarding Plans will ensure local safeguarding services comply with timescales for responding to allegations of abuse Internal Audit Developing Adult Safeguarding IT system Establish baseline Performance level set once baseline is established March 2016 (end of Year 2) and ongoing 3. Service users are enabled to exercise choice and control whenever possible in relation to the management of allegations of abuse 4. Percentage of older people who have had a NISAT specialist risk assessment completed which indicates a specialist safeguarding assessment is required Service users/ carers feedback NISAT reports Delegated Statutory Functions Reports Establish baseline Performance level set once baseline is established Establish baseline Performance level set once baseline is established March 2016 (end of Year 2) and ongoing March 2016 (end of Year 2) and ongoing 117

Standard 18: Development of Protection Plans Health and social care organisations will work in partnership with service users, their carers and/or representatives and other relevant agencies so that any Protection Plan is tailored to meet the needs of the older person. Rationale It has been shown that the disclosure of abuse and the subsequent investigation can be a very stressful process for older people. Health and social care organisations should bear the older person s emotional health and wellbeing in mind at all stages of the safeguarding process. It is important that the purpose of any health and social care intervention is clear to the older person and their carers or advocates, and that these are in proportion to the needs and circumstances of the individual. The identification, assessment, protection and care of older people who have been abused are frequently an interagency and inter-disciplinary responsibility. Different levels of intervention may be required when responding to such abuse. The appropriate intervention will depend on the specific circumstances, the wishes and circumstances of the older person, and their capacity to make decisions. There may be occasions when the decision is taken not to proceed further with the safeguarding process. Responses to the abuse of an older person should include: a clear, agreed statement of the risk faced by them; a clear statement of the roles and responsibilities of each agency or organisation involved in both the investigation and the Protection Plans; a named worker to liaise with the older person; the provision of options for the future care, or support; and the provision of an individualised Care, or Protection Plan which includes a timetable of regular reviews. 118

Evidence 1. Association of Directors of Social Services (2005) Safeguarding Adults: National Framework of Standards for Good Practice and Outcomes in Adult Protection Work. London: Association of Directors of Social Services. http://www.adass.org.uk/images/stories/publications/guidance/safeguarding.pdf 2. Department of Health (2000) No Secrets: Guidance on Developing and Implementing Multi-agency Policies and Procedures to Protect Vulnerable Adults from Abuse. London: Department of Health. http://www.dh.gov.uk/en/.../publicationspolicyandguidance/dh_4008486 3. Department of Health, Social Services and Public Safety (2010). Adult Safeguarding in Northern Ireland: Regional and Local Partnership Arrangements. Belfast: Department of Health, Social Services and Public Safety. http://www.dhsspsni.gov.uk/.../safeguarding...adults/safeguarding_vulnerable_adultsresourcelibrary.htm - 4. Department of Health, Social Services and Public Safety (2003). Good Practice in Consent. Belfast: Department of Health, Social Services and Public Safety. http://www.dhsspsni.gov.uk/consent-referenceguide.pdf 5. Northern Health and Social Services Board (2006) Safeguarding Vulnerable Adults: Regional Adult Protection Policy and Procedural Guidance. http://www.nhssb.n- i.nhs.uk/.../social_services/safeguarding_vulnerable_adults.pdf - 6. United Nations (1948) Universal Declaration of Human Rights. http://www.un.org Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Police Service Northern Ireland RQIA 119

Quality Dimensions Person-centred - Ensures that the older person is an active partner in any investigation of abuse and any related Protection Plan. The safeguarding process should be focused on the individual and responsive to their changing circumstances. Safety - Ensures that the rights of all parties, including the older person, their family, and carers are maintained. Individualised Protection Plans should also result in a reduction of the risk of the older person being abused. Timeliness - The safeguarding process is taken forward without undue delay. Effectiveness and Efficiency - Good quality partnerships with older people as service users and other agencies and organisations should lead to more effective Protection Plans put in place, and make more efficient use of organisational resources. Performance Indicator 1. NIASP will establish an Adult Safeguarding Forum which will ensure that users of safeguarding services contribute to the design and commissioning of safeguarding services Data Source Adult Safeguarding Forum Action Plan and Annual Reports to NIASP Anticipated Performance Level Date to be achieved by 100% March 2016 (end of Year 2) and ongoing 120

2. Number of people and/or their advocates who have their need for safeguarding met through their participation in processes such as care planning, protection planning, case conferences, family group conferences Delegated Statutory Functions Reports Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) and ongoing 3. Number of Protection Plans in place as a percentage of referrals accepted by Safeguarding services Delegated Statutory Functions Reports Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) and ongoing 121

Standard 19: Safeguarding People (Generic) All Health and Social Care staff should ensure that people of all ages are safeguarded from harm through abuse, exploitation or neglect. Rationale: A wide range of people, for a variety of reasons, have been shown to be at risk of harm through abuse, exploitation or neglect. People of all ages have the right to be safeguarded from such harm; to have their welfare promoted; and their human rights upheld. At the same time, they have the right to choose how to lead their lives, provided their lifestyle choices do not impact adversely on the safeguarding needs of others or, within the requirements of the law, of themselves. Decision making in this regard will have to pay due consideration to the age, maturity and capacity of the person. In this Standard, the term safeguarding is intended to be used in its widest sense, that is, to encompass both preventive activity, which aims to keep people safe and prevent harm occurring, and protective activity, which aims to provide an effective response in the event that there is a concern that harm has occurred or is likely to occur. All HSC staff and staff providing services on behalf of the HSC have a dual responsibility with regard to safeguarding: (a) to ensure that all service users are treated with respect and dignity and are kept safe from poor practice that could lead to harm; and (b) that all staff are alert to the indicators of harm from abuse, exploitation or neglect wherever it occurs and whoever is responsible; and know how and where to report concerns about possible harm from abuse, exploitation or neglect whether these relate to the workplace or the wider community. Effective safeguarding can ensure that people are safeguarded and their welfare promoted whether in their own homes; in the community; in families; and in establishments such as children s homes; secure accommodation; residential care and nursing homes; and hospitals. Through safeguarding and in conjunction with positive engagement of individuals, (and as appropriate their family and carers) effective prevention and potential for early intervention is enhanced and promoted and care and service plans are supported to deliver better outcomes. 122

Where safeguarding is promoted, staff are empowered to act as advocates to safeguard vulnerable individuals and professional advocacy and counselling services are provided where required. A learning culture is also evident and staff are knowledgeable about safeguarding and keep abreast of local and national developments and learning, including enquiries, serious case reviews, case management reviews, inquiries and reports. The quality of outcomes is more consistent, regardless of age, disability, gender, ethnic origin, religion, language, sexuality, political opinion, who pays for their care or their access to HSC provided or purchased services. Application in the wider community of knowledge and expertise gained in the workplace serves to safeguard people more broadly and more generally. The cycle of abusive behaviour(s) and/or neglect is broken. Evidence 1. European Convention on Human Rights http://www.hri.org/docs/echr50.html 2. The Protocol to Prevent, Suppress and Punish Trafficking in Persons, especially Women and Children http://www.dhsspsni.gov.uk/index/hss/child_care/child_protection/child_protection_guidance.htm 3. UN Convention on the Rights of the Child http://www2.ohchr.org/english/law/crc.htm 4. Council of Europe Convention on the Protection of Children against Sexual Exploitation and Sexual Abuse http://conventions.coe.int/treaty/en/treaties/html/201.htm 5. UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment http://www2.ohchr.org/english/law/cat-one.htm 6. A Guide to the Human Rights Act 1998: Third Edition (Department for Constitutional Affairs, London, October 2006) http://www.justice.gov.uk/guidance/docs/act-studyguide.pdf 123

7. Improving the Patient & Client Experience 5 Standards: Respect, Attitude, Behaviour, Communication and Privacy and Dignity (DHSSPS, 2008) http://www.dhsspsni.gov.uk/improving_the_patient_and_client_experience.pdf 8. Co-operating to Safeguard Children (DHSSPS, 2003) - http://www.dhsspsni.gov.uk/show_publications?txtid=14022 9. Ageing in an Inclusive Society - Promoting the Social Inclusion of Older People (OFMDFM, 2005) currently under review http://www.ofmdfmni.gov.uk/ageing-strategy.pdf 10. Report of the Promoting Social Inclusion Working Group On Disability (OFMDFM, 2009) - access through: http://www.ofmdfmni.gov.uk/disability-promoting-social-inclusion 11. A Life Like Any Other? Human Rights of Adults with Learning Disabilities (The Joint Committee on Human Rights, Seventh Report of Session 2007-08 Volume 1) - http://www.publications.parliament.uk/pa/jt200708/jtselect/jtrights/40/4002.htm 12. European report on preventing elder maltreatment (World Health Organisation, 2011) - http://www.euro.who.int/en/home Responsibility for Delivery/Implementation: HSC Board & LCGs Public Health Agency (PHA) HSC Trusts Primary Care Delivery and Implementation Partners: PCC RQIA SBNI, NIASP & LASPs PSNI Other statutory agencies & voluntary, community and private sector 124

Quality Dimensions Safety - Promotion of self-aware practice; supportive of person-centred engagement; fosters awareness and opportunity for early intervention in poor practice/potentially abusive dynamics; and promotion of individualised safety plans where these are indicated, thereby enhancing services and safeguarding awareness and responses. Effectiveness - Promotion of self-reliance and personal and professional safeguarding behaviours; builds personal and professional safeguarding capacity; promotion of the welfare of individuals; protection from mistreatment; impairment of health and development is prevented; and individuals are kept safe from harm. A better focus on prevention reduces poor practice; promotes recovery; reduces complaints; breaks the cycle of abusive behaviour and/or neglect; and reduces or removes the need to have recourse to emergency services. Person-centred - Safeguarding interventions must be tailored to the presenting circumstances and to the needs and choices of the individual (provided these do not impact adversely on the safeguarding needs of others or, within the requirements of the law, of him or herself) and his/her circumstance. Decision making in this regard will have to pay due consideration to the age, maturity and capacity of the person. Safeguarding responses are non-discriminatory, and seek to ensure that people of all ages at risk of harm are offered support to keep them safe from harm and to protect them when harm occurs. Services are better able to support individuals, families and carers thereby aiding improvement of relationships; and to help perpetrators to address their behaviours. 125

Performance Indicator: Data source: 1. All HSC Organisations and organisations providing services on behalf of the HSC have a Safeguarding Policy in place, which is effectively aligned with other organisational policies (e.g. recruitment, governance, complaints, SAIs, training, supervision, etc). The Safeguarding Policy is supported by robust procedures and guidelines HSC and provider Organisation annual reports HSC Governance Reviews, e.g. Complaints; SAIs, etc HSC Statutory Functions Reports and Corporate Parent Reports SBNI, NIASP & LASP Annual Reports RQIA Reports & Reviews Case Management Reviews (CMRs) Serious Case Reviews (SCRs) Anticipated Performance Level: Establish baseline Performance levels to be determined once baseline established Date to be achieved by: March 2014 2. All HSC Organisations and organisations providing services on behalf of the HSC have Safeguarding Plans in place As above Establish baseline Performance levels to be determined March 2014 126

once baseline established 3. All HSC Organisations and organisations providing services on behalf of the HSC have safeguarding champions in place to promote awareness of safeguarding issues in their workplace As above Establish baseline Performance levels to be determined once baseline established March 2014 127

SECTION 6 CARERS Overview of Carers Standards Introduction: Many vulnerable older people could not lead independent lives in their communities without support from a family member or friend in the role of carer. An increasing number of carers are older people. These standards aim to protect their interests to ensure they can continue to care for as long as they wish and without jeopardising health, wellbeing, financial security or reducing expectations of a reasonable quality of life. Services should recognise carers as individuals in their own right and as partners in care provision and support. 1. Identifying and Supporting Carers (Generic Standard): All HSC staff should identify carers (whether they are parents, family members, siblings or friends) at the earliest opportunity to work in partnership with them and to ensure that they have effective support as needed. 2. Identification and Recognition of Carers: Older carers and carers of older people should be identified as early as possible by staff in relevant organisations working together to improve awareness and recognition of their role in a range of settings. 3. Information for Carers: Older carers and carers of older people will be offered information to support them in making choices and throughout their caring journey. This should be tailored to individual need, accurate, accessible and appropriate. 4. Financial Advice and Information for Carers: Carers will be signposted to organisations specialising in benefits and financial advice relevant to their role as early as possible to minimise the impact of caring on their standard of living. 5. Flexible, Responsive Services: Older carers and carers of older people will have timely access to flexible and responsive services in order to meet their individual needs. 6. Respite for Carers: Older carers and carers of older people will have timely access to appropriate respite breaks to meet different individual needs and circumstances. 128

7. Carer Health and Well-being: All older carers and carers of older people will be supported to look after their physical and emotional health and wellbeing by all relevant organisations. 8. Involving Carers: Older carers, carers of older people and their representative organisations should be treated as equal partners and be involved in service planning/delivery/monitoring. 129

Carers Standard 20: Identifying & Supporting Carers (Generic) All Health & Social Care staff should identify carers (whether they are parents, family members, siblings or friends) at the earliest opportunity to work in partnership with them and to ensure that they have effective support as needed. Rationale Carers are central to providing health and social care. People want to live in their own homes as independently as possible and family caring is critical in achieving this goal. Breakdown in caring has a major impact on readmission rates to hospital and unnecessary admissions to residential and nursing home care placements. Caring is both a demanding and rewarding activity. Evidence shows that unsupported caring can have a negative impact on the physical, social and emotional well being of an adult carer. It is in everyone s interest to ensure that carers can continue to care for as long as they wish and are able to, without jeopardising their own health and wellbeing or financial security, or reducing their expectations of a reasonable quality of life. Young carers (children and young people up to the age of 18 years who have a substantive caring role for a member of their family) often do not have an alternative but to be a carer. These children can be lonely, isolated, lose friendships and miss out on education and social activities. Young carers are frequently involved in activities that are developmentally inappropriate and the impact on their lives is unknown. Many young carers go unidentified. This highlights the need to identify young carers and provide support and assistance which will promote their health, development and inclusion in educational and social activities. Early intervention, individually tailored to the needs of the carer and the cared for person, can be crucial in avoiding breakdown in the caring role. Forming meaningful partnerships with carers and making agreements with them about support to be provided is essential. Carers identify their requirements as respite care, information, personal care for the cared for person and practical and emotional support to continue in their role. This highlights the need for service planning and commissioning based on partnership working between statutory and independent sector and involvement of carers or their representatives 130

to shape future services. To enable carers to access the right information, support and services, current methods for identifying carers and encouraging them to acknowledge their caring role need to be enhanced. Under the Carers and Direct payments Act, all staff have a duty to inform carers. Staff should be particularly proactive in identifying the presence of younger and older carers. One of the most important and far-reaching improvements in the lives of carers will be brought about by how health and social care staff view and treat them. Changes in staff knowledge of carers issues could promote a more positive attitude to carers and this would make a significant difference to the lives of carers. Services should recognise carers both as individuals in their own right and as key partners in the provision of care and support. Evidence 1.Department of Health, Social Services and Public Safety (2006) Caring for Carers Recognising, Valuing and Supporting the Caring Role. Available at http://www.dhsspsni.gov.uk/ec-dhssps-caring-for-carers.pdf 2. Department of Health, Social Services and Public Safety / Department for Social Development (2009) Review of the Support Provision for Carers. Available at www.dhsspsni.gov.uk/review-of-support. 3. Department of Health, Social Services and Public Safety (2009). Circular HSS (ECCU) 2/2009, Regional Carers Support and Needs Assessment Tool Available at http://www.dhsspsni.gov.uk/eccu2-09.pdf 4. Department of Health, Social Services and Public Safety (2006). Circular HSS (ECCU) 4/2006, Identification of Carers. Available at http://www.dhsspsni.gov.uk/hss eccu 4-2006_carers_circular_-_signed.doc.pdf. 5. Department of Health, Social Services and Public Safety (2008). Circular HSS (ECCU) 3/2008, Good Practice Guidance Training for Carers. http://www.dhsspsni.gov.uk/microsoft_word_-_circular_hss eccu 3_2008_- _implementation_of_carers strategy.pdf 6. Earley L, Cushway D and Cassidy T (2007) Children s perceptions and experiences of care giving: A focus group study. Counselling Psychology Quarterly. 20. 1. pp.69 80. 7. Evason, E. (2007) Who Cares Now? Changes in Informal Caring 131

1994 and 2006. Research Update 51. Belfast: ARK Publications. Available at www.ark.ac.uk 8. Northern Ireland Statistics and Research Agency (2001) Northern Ireland Census of population. Available at www.nisra.gov.uk 9. Olsen R (1996) Young Carers: challenging the facts and politics of research into children and caring. Disability and Society, 11 (1), 41-54 10. Patient & Client Council NI (2011) A report of the experiences and circumstances of 16 year old carers. Available at http://www.patientclientcouncil.hscni.net/uploads/research/young_carers_in_northern_irel and.pdf 11. Social Policy Research Unit, University of York (2004) Hearts and Minds -The Health Effects of Caring, Michael Hirst. Available at www.york.ac.uk 12. Southern Health and Social Care Trust (2011) General Practitioners Carers Support Project: Project Report. Available at www.southerntrust.hscni.net/services/carers 13. Schubotz, D. and McMullan G. (2010) The Mental and Emotional Health of 16-Year Olds in Northern Ireland: Evidence from the Young Life and Times Survey. Belfast: Patient and Client Council Report. 14. Tommis, Y. and Robinson, C.A. (2009) Carers Interventions Assessed. Wales Office of Research and Development. 132

Responsibility for Delivery / Implementation HSC Board Public Health Agency HSC Trusts Quality Dimensions Delivery and Implementation Partners Primary Care GPs, LCGs Independent Sector DSD, DENI Person-centred - Carers will feel valued and able to access the support they need. Staff will be facilitated to understand and value the role of carers. Carers will be recognised as real and equal partners in the delivery of care. All carers, irrespective of age, who they care for or where they live will be directed toward appropriate agencies that can offer advice and support. Safe - Carers will be encouraged to identify themselves as carers and to access information and support to protect and promote their own health and well-being and minimise the negative impact of caring Effectiveness - Involving carers in the planning, delivery and evaluation of services improves outcomes for the carer and cared for person. Carers will be identified and supported best through partnerships between the statutory and voluntary sector and by good referral processes. Carers will be identified and signposted to help and support as early as possible in their journey and at times of crisis/transition. Performance Indicators 1. Number of front line staff in a range of settings participating in Carer Awareness Training Programmes Data Source Trust Training Report (including Induction programmes) Anticipated Performance Level 20% 50% Date to be achieved by March 2015 March 2016 2a. The number of carers who are offered Carers Assessments Health & Social Care Board/ DHSSPSNI returns Improvement targets set by HSCB in conjunction with Reviewed annually 133

2b. The percentage of carers who participate in Carers Assessments Carers Strategy Implementation Group Improvement targets set by HSCB in conjunction with Carers Strategy Implementation Group Reviewed annually 134

Standard 21: Identification and Recognition of Carers Older carers and carers of older people should be identified at the earliest opportunity by all staff in relevant organisations working together to improve awareness and recognition of the carer s role in a range of settings. Rationale Carers are central to providing health and social care. People want to live in their own homes, as independently as possible and family, friends and neighbours caring is critical in achieving this goal. Many carers still do not recognise themselves as carers. They think of themselves as a parent, spouse, son, daughter, brother, sister, friend or neighbour. To enable carers to access the right information, support and services, current methods for identifying carers and encouraging them to acknowledge their caring role need to be enhanced. Partnerships between the statutory and voluntary sector are vital in identifying hidden carers as voluntary organisations are often instrumental in helping carers identify themselves. All staff and volunteers in statutory, voluntary and community organisations need to be particularly proactive in identifying the presence of younger and older carers. Carer awareness training for all health and social care staff is central to the early identification of carers. One of the most important and far-reaching improvements in the lives of carers will be brought about by how health and social care staff view and treat them. Changes in staff knowledge of carers issues could promote a more positive attitude to carers and would make a significant difference to their lives. Evidence 1. Department of Health, Social Services and Public Safety (2006) Caring for Carers Recognising, Valuing and Supporting the Caring Role. http://www.dhsspsni.gov.uk/caring_for_carers.pdf 2. Department of Health, Social Services and Public Safety / Department for Social Development (2009) Review of the Support Provision for Carers. 135

http://www.dhsspsni.gov.uk/review-of-support.pdf 3. Princess Royal Trust for Carers / Royal College of General Practitioners (2009) Supporting Carers: An Action Guide for General Practitioners and their Teams. http://www.rcgp.org.uk/pdf/carers%20action%20guide.pdf 4. Southern Health and Social Care Trust (2011) General Practitioners Carers Support Project: Project Report. http://www.promotingwellbeing.info Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Quality Dimensions Delivery and Implementation Partners Independent Sector Voluntary and Community Sector DSD Person-centred - Carers will feel valued and able to access the support they need. Staff will be facilitated to understand and value the role of carers. Safety - Carers will be encouraged to identify themselves as carers and to access information and support to protect and promote their health and wellbeing. Timeliness - Carers will be identified as early as possible in their journey. Effectiveness - Carers will be identified and supported best through partnerships between the statutory and voluntary sector and by good referral processes. Equity - Carers will be recognised as real and equal partners in the delivery of care agreed by the Health and Social Care Board. 136

Performance Indicator 1a. The number of carers who are identified by GP practices 1b. The percentage of carers who have been referred for support by their GP Data Source Quality and Outcomes Framework for GPs and Proposed Carers Survey Anticipated Performance Level Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) 137

Standard 22: Information for Carers Older carers and carers of older people will be offered information to support them in making choices and throughout their caring journey. This should be tailored to individual need, accurate, accessible and appropriate. Rationale Carers need specific information for older people on available services and supports to allow them to make informed choices. It is clear from available research that not all carers get the appropriate information at the appropriate time. Carers need information on a wide range of issues. They need to know about the potential impact of illnesses on the cared for person, Trust services and other support organisations and how to express their views. Current methods for identifying carers and encouraging them to acknowledge their caring role, needs to be improved to enable carers to access the right information, support and services. Carer awareness training to all health and social care staff is central to this improvement. Evidence 1. Banks, P. (2005) Commissioning Care Services for Older People: Achievements and Challenges in London. London: Kings Fund. http://www.kingsfund.org.uk/document.rm?id=5523 2. Department of Health, Social Services and Public Safety (2006) Caring for Carers, Recognising, Valuing and Supporting the Caring Role. http://www.dhsspsni.gov.uk/ec-dhssps-caring-for-carers.pdf 3. Department of Health, Social Services and Public Safety / Department for Social Development (2009) Review of the Support Provision for Carers. http://www.dhsspsni.gov.uk/review-of-support. 138

Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Department of Social Development Quality Dimensions Person-centred - Comprehensive and clear information will be tailored to meet individual needs, improve understanding and give a sense of control. Safety - The service will provide comprehensive information on services and defined signposting routes for situations where the service contacted does not have appropriate expertise including emergency and out-of-hours contacts. Timeliness - Carers will be identified as early as possible in their journey. The identification of key stages in the process will help individuals access the right level of information when they need it. Effectiveness - Carers will be involved in the development, regular evaluation and updating of information provided by the service. The service is widely publicised and clear to those who may not define themselves as carers. Equity - Carers will be recognised as real and equal partners in the delivery of care. Information is made available in a range of formats to address the ongoing needs of a diverse audience. 139

Performance Indicator 1a Health and Social Care Trusts will produce a local information pack for carers (complementary to the DHSSPS Carers A-Z) and information in a range of appropriate formats 1b Trusts will develop a communication plan to demonstrate how both staff and carers are to be made aware of the available information Data Source Anticipated Performance Level Date to be achieved by Trust Audit 100% March 2015 (end of Year 1) and ongoing Trust Audit 100% March 2015 (end of Year 1) and ongoing 140

Standard 23: Financial Advice and Information for Carers All carers will be signposted to organisations specialising in benefits and financial advice relevant to their role, as early as possible to minimise the impact of caring on their standard of living. Rationale Many carers experience financial hardship as a result of caring. One in three long-term carers struggle to pay essential bills. Approximately 30% of carers reported that they were 'just getting by' and 9% find it difficult to manage financially. There are particular problems for carers who are forced to give up work in order to care. There is a strong relationship between the number of hours of caring per week and the length of time caring and the poverty level of carers. Many people are unaware of how the benefits system works: every year in Northern Ireland more than 4m of Carers Allowance - the main benefit to which carers are entitled - is unclaimed. Even when full benefits are claimed, carers can remain in poverty, due to the extra costs of disability and caring and no potential to earn extra income. The situation appears to be worsening with half of carers questioned in 2008 in debt as a result of caring, compared to a third in 2007. Evidence 1.Carers UK (2010) Carers Missing Millions. http://www.carersuk.org 2. Carers UK (2007) Real Change Not Short Change. http://www.carersnet.org/docs/research/realchange.pdf 3. Carers UK (2008) Carers in Crisis A Survey of Carers Finances. http://www.carersuk.org/professionals/resources/research-library/item/.../133-4. Carers UK (2006) In the Know. http://www.carersuk.org/media/k2/attachments/in_the_know.pdf 5. Northern Ireland Statistics and Research Agency (2001) Northern Ireland Household Panel Survey. http://www.ark.ac.uk/services/olderpeople1.pdf 141

6. Northern Ireland Statistics and Research Agency (2001) Northern Ireland Census of population. http://www.nisra.gov.uk/census.html 7. Her Majesty s Stationery Office (2008) Valuing and Supporting Carers: House of Commons Work and Pensions Committee Fourth Report of Session 2007-08. http://www.publications.parliament.uk/pa/cm200708/cmselect/cmworpen/485/485i.pd Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Social Security Agency Quality Dimensions Person-centred - Comprehensive and clear information is tailored to meet individual needs, improve understanding and give a sense of control. Safety - Carers receive signposting to comprehensive information about services which enables them avoid unnecessary financial hardship. Timeliness - Carers are identified and signposted to help and support as early as possible in their journey. Effectiveness - Carers are referred to sources of advice not only for benefits but also regarding housing, heating and transport costs, for debt advice where necessary, and to specialists in financial and legal services where estate or trust planning and Power of Attorney may need to be used. Equity - Carers irrespective of age, who they care for or where they live will be directed to appropriate agencies offering advice and support. 142

Performance Indicator 1. Number of carers known to Trusts who have been signposted for financial advice Data Source Trust Audit Anticipated Performance Level Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) and ongoing 2. Feedback from a sample of carers about their experiences regarding financial issues Proposed Carer Survey Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) and ongoing 143

Standard 24: Flexible, Responsive Services Older carers and carers of older people will have timely access to flexible and responsive services in order to meet their individual needs. Rationale Government policies outline the need to ensure that service providers make practical support for carers a high priority with the recognition that the continuing contribution of carers provide the backbone of caring for people in the community. Significant resources have been made available to health and social care organisations to develop innovative and responsive services, which will optimise choice, promote independence and ensure fairness and equity in order to meet the needs of carers who carry out this vital role. Early intervention, individually tailored to the needs of the carer and the cared for person can be crucial in avoiding breakdown in the caring role. Breakdown in this role, in addition to limited domiciliary care provision, has a major impact on readmission rates to hospital and unnecessary admissions to residential and nursing home care placements. It is important for Trusts to have arrangements in place to deal with emergency back-up for carers. 69% of carers report some level of stress and identify their needs for service provision as respite care, information, personal care for the cared for person and practical and emotional support to continue in their role. This highlights the need for service planning and commissioning based on partnership working between the statutory and voluntary sector and involvement of the carer or their representatives to shape future services. There is also evidence of an increase in the number of young carers and older carers over 65. While the latter group may be more available to provide caring due to retirement, service planning should consider the impact of this rise as they may require help themselves, may have reducing capacity to care or have difficulty requesting or accepting help. 144

Evidence 1. Department of Health, Social Services and Public Safety (2006) Caring for Carers: Recognising, Valuing and Supporting the Caring Role. http://www.dhsspsni.gov.uk/caring_for_carers.pdf 2. Department of Health, Social Services and Public Safety (2005) Carers Assessment and Information Guidance. http://www.dhsspsni.gov.uk/ec-carers-assessment-information-guidance.pdf 3. Department of Health, Social Services and Public Safety (2009). Circular HSS (ECCU) 2,2009 Regional Carers Support and Needs Assessment Tool http://www.dhsspsni.gov.uk/eccu2-09.pdf 4. Department of Health, Social Services and Public Safety (2007) Promoting Partnerships in Caring: Inspection of Social Care Support Services for Carers of Older People, Overview Report. http://www.dhsspsni.gov.uk/promoting_partnerships_in_care.pdf 5. Department of Health, Social Services and Public Safety / Department for Social Development (2009) Review of the Support Provision for Carers. http://www.dhsspsni.gov.uk/review-of-support. 6. Department of Health, Social Services and Public Safety (2006) Survey of Carers of Older People in Northern Ireland. http://www.dhsspsni.gov.uk/nicarerreport.pdf 7. Department of Health, Social Services and Public Safety (2002) The Carers and Direct Payments Act (NI). http://www.dhsspsni.gov.uk/ec-carers-assessment-information-guidance.pdf 8. Northern Ireland Statistics and Research Agency (2001) Northern Ireland Census of Population. http://www.nisranew.nisra.gov.uk/census/census2001output/index.html 145

Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Quality Dimensions Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Person-centred - Carers should be recognised as experts in their own care and their needs and views considered in care planning. Safety - Services are delivered by appropriately skilled and competent staff. Carers are offered individualised training to enable them provide appropriate care. Timeliness - Carers will have access to timely, convenient services responsive to their practical and emotional needs throughout their caring role. Effectiveness - Carers and their representatives will be fully involved in all aspects of planning, commissioning, delivery and evaluation of services. Efficient - Existing services will be monitored and evaluated and new services designed on a needs-led basis. Carers needs, will be reviewed regularly. Equity - Carers will be provided with support and services in their own right. 146

Performance Indicator 1. Number of carers with a completed carer s assessment Data Source Health and Social Care Board returns Anticipated Performance Level 40% 50% Date to be achieved by March 2015 (end of Year 1) March 2016 (end of Year 2) 2. Number of carers who experience flexible and responsive services to enable them to continue their caring role 3. Carers level of satisfaction with response to instances of emergency support need 60% Carers survey 70% 75% 80% Carers survey. Baseline established Improvement target set and monitored March 2017 (end of Year 3) March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) March 2015 (end of Year 1) March 2016 (end of Year 2) 147

Standard 25: Respite for Carers Older carers and carers of older people will have timely access to appropriate respite breaks to meet different individual needs and circumstances. Rationale Carers have a right to a life outside caring. This means time to pursue their own interests, see their friends, go to church or catch up with work around the house. Carers need breaks from caring but too often they do not get the opportunity or the breaks are provided in an inappropriate way. Carers who seek respite should not encounter problems in obtaining support and should not feel undervalued by health and care professionals. Carers often have little choice about the timing or the type of break. A range of respite care must be provided to suit the needs of both the carer and the person being cared for - week-long, one evening a week, weekend, overnight, short breaks in residential care different options will suit different people and these different options may also be appropriate at different times Respite care should not be seen exclusively as alternative residential care and could often be more appropriately, provided by somebody coming into the home. There is also a need for emergency cover to be available, for example, for carer illness. What carers want most of all during a break from caring is to know that the person being cared for is well looked after and safe. Carers needs should be considered on an individual basis and they should have a choice about the type of service available to give them a break and about the timing of it. 148

Evidence 1. Department of Health, Social Services and Public Safety (2006) Caring for Carers: Recognising, Valuing and Supporting the Caring Role. http://www.dhsspsni.gov.uk/caring_for_carers.pdf 2. Department of Health, Social Services and Public Safety (2007) Overview Report, Promoting Partnerships in Caring Inspection of Social Care Support Services for Carers of Older People. http://www.dhsspsni.gov.uk/promoting_partnerships_in_care.pdf 3. Department of Health, Social Services and Public Safety/ DSD (2009) Review of the Support Provision for Carers. http://www.dhsspsni.gov.uk/review-of-support.pdf 4. Ingleton,C. Payne,S. Nolan,M et al. (2003) Respite in Palliative Care: a Review and Discussion of the Literature. Palliative Medicine 17: pp. 567-575. 5. King s Fund (1999) Quality Standards for Local Carer Support Services. London: Kings Fund. http://www.kingsfund.org.uk 6. Princess Royal Trust for Carers (2008) Putting People First without Putting Carers Second. London: Princess Royal Trust for Carers / Crossroads Caring for Carers. 7. Solihull Partnership (2006) The Future is Ours A Quality of Life Strategy for Older People. 2006-2013. http://www.solihull.gov.uk/attachments/thefuture_is OursPart1.pdf 8. Tommis,Y. and Robinson,C.A. (2009) Carers Interventions Assessed. Wales Office of Research and Development. 9. Wanless,D and Forder,J. (2006) Social Care Review: Securing Good Social Care for Older People. London: Personal Social Services Research Unit: London School of Economics: Kings Fund. http://www.kingsfund.org.uk/publications/securing_good.html 149

Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Quality Dimensions Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Person-centred - Respite support should meet both the carers own needs and the needs of the cared-for person. Interventions such as emotional, practical, befriending, peer group support, etc to be used as respite support initiatives. Safety - Carers are able to get emergency respite care. Contingency/risk planning is in place both for the carer and the caredfor person if an emergency or crisis situation should occur. Timeliness - Carers are offered respite as early as possible and especially at times of crisis/transition. Effectiveness - Respite care outcomes are monitored to ensure they are meeting the carer s needs. Equity - Carers access a range of supports and health initiatives. Performance Indicator 1a. The numbers of carers who have been assessed as requiring respite 1b. The number of carers who receive respite 2. The number of carers who have been assessed as requiring respite and who do not receive respite Data Source Health and Social Care Board returns Health and Social Care Board returns 150 Anticipated Performance Level Establish baseline. Performance level set once baseline is established Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) and ongoing March 2015 (end of Year 1) and ongoing

Standard 26: Carer Health and Wellbeing All older carers and carers of older people will be supported to look after their own physical and emotional health and wellbeing by all relevant organisations. Rationale Caring is both a demanding and rewarding activity. If unsupported, it can have a negative impact. Evidence suggests that carers are more likely to suffer from higher levels of stress than non-carers, with significant implications for physical and emotional health. Research carried out by Carers UK shows that carers who provide high levels of care for sick or disabled relatives and friends, unpaid, are more than twice as likely to suffer from poor health. In 2001, nearly 66% of Northern Irish carers reported health problems, with 31% having two or more problems. 8% of carers regularly do not see anyone outside the home and 10% have no-one to talk to if they are in crisis. Carers are twice as likely as non-carers to suffer from a great deal of worry or stress. There is evidence of the impact of caring on health and wellbeing, and that carers are more likely to experience high levels of 'psychological distress', including anxiety, depression, loss of confidence and selfesteem. The number of people aged over 75 years will increase by 53% to 176,000 in 2023. This will require an increased level of support from carers, many of whom will themselves be older. Approximately 33,247 people aged 60 and over are looking after others husbands or wives with dementia, adult children with mental health or learning difficulties, much older parents or in-laws, other family members and friends with a range of support needs. Carers aged over 65 are almost twice as likely as carers aged 25-44 to be caring for over 50 hours a week. The consequences of this disproportionate demand will need to be addressed in order to ensure that the health and wellbeing of a generation of older carers is not adversely affected. 151

Evidence 1. Department of Health, Social Services and Public Safety (2006) Caring for Carers: Recognising, Valuing and Supporting the Caring Role. http://www.dhsspsni.gov.uk/ec-dhssps-caring-for-carers.pdf 2. Department of Health, Social Services and Public Safety (2009). Circular HSS (ECCU) 2,2009 Regional Carers Support and Needs Assessment Tool. http://www.dhsspsni.gov.uk/eccu2-09.pdf 3. Department of Health, Social Services and Public Safety, Department for Social Development (2009) Review of the Support Provision for Carers. http://www.dhsspsni.gov.uk/review-of-support.pdf 4. Department of Health, Social Services and Public Safety (2006) Survey of Carers of Older People in Northern Ireland http://www.dhsspsni.gov.uk/nicarerreport.pdf 5. Hutton, S. (2000) Caring Relationships Over Time: Predicting Outcomes for Carers. University of York: Social Policy Research Unit. 6. Northern Ireland Statistics and Research Agency (2001) Northern Ireland Household Panel Survey. http://www.ark.ac.uk/services/olderpeople1.pdf 7. Social Policy Research Unit, University of York (2004) Hearts and Minds -The Health Effects of Caring, Hirst, M. http://www.york.ac.uk/inst/spru/pubs/pdf/hearts&minds.pdf 8. Elvish, R., Lever, S., Johnstone, J., Cawley, R., & Keady, J. (2012). Psychological interventions for carers of people with dementia: A systematic review of quantitative and qualitative evidence. British Association for Counselling and Psychotherapy. 152

Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care/Pharmacy Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Quality Dimensions Person-centred - Carers individual needs will be met through access to a range of supports and initiatives. Safety - Carers will be given the opportunity to access carer assessments, support services, training and other initiatives to help maintain their own health and well-being and minimise the negative impact of caring. Timeliness - Carers will be offered supports as early as possible and at times of crisis/transition. Effectiveness - Carers will have access to health initiatives and support services which help them maximise their own level of health and wellbeing. Equity - All carers irrespective of age, who they care for, or where they live will have access to appropriate supports and health initiatives. 153

Performance Indicator Data Source Anticipated Performance Level Date to be achieved by 1. The number of carers who participate in health and wellbeing programmes and events for carers Trust Audit Establish baseline Set performance level once baseline established March 2015 (end of Year 1) and ongoing 2. The number of carers who receive training appropriate to individual needs e.g. manual handling, stress management, knowledge about symptoms and potential impacts from the condition of person being cared for Trust Audit Establish baseline Performance targets to be set for when baseline established March 2015 (end of Year 1) and ongoing 154

Standard 27: Involving Carers Older carers and carers of older people should be treated as equal partners. Consequently carers and their representative organisations will be actively involved in the planning, delivery and monitoring of services. Rationale When carer involvement works well it is possible to offer a service, which is truly based on people s needs, enhancing choice for individuals and creating an environment in which carers and workers are treated with mutual respect and consideration. Involving carers in the commissioning, planning and reviewing of the services for the person they care for receives is fundamental to improving services. Carers are uniquely placed with their experience to comment on what works well and what needs to be improved. Carers should be recognised as experts, and as partners in care. Therefore organisations should ensure that there are systems and forums to routinely and formally consult with carers about services. Carers have said that there must be carer-friendly opportunities that facilitate involvement on specific issues, or with specific services. There also needs to be a more flexible approach to engagement other than solely being asked to attend meetings. Support needs to be provided to enable carers to be involved including training, transport, expenses and alternative care. A proactive approach is needed to involve carers who are hidden or under-represented demographics including groups listed in Section75 of the Northern Ireland Act 1998. Carers also want to have feedback and evidence of how their views have driven and enhance service improvement. 155

Evidence 1. Department of Health, Social Services and Public Safety (2006) Caring for Carers: Recognising, Valuing and Supporting the Caring Role. http://www.dhsspsni.gov.uk/ec-dhssps-caring-for-carers.pdf 2. Department of Health, Social Services and Public Safety/ Department for Social Development (2009) Review of the Support Provision for Carers. http://www.dhsspsni.gov.uk/ec-carers 3. Department of Health, Social Services and Public Safety (2008) Standards for Adult Social Care Support Services for Carers. http://www.dhsspsni.gov.uk/standards_for_adult_social_carer_support_services_for_ carers.pdf 4. Department of Health, Social Services and Public Safety (2007) Guidelines on Personal and Public Involvement. http://www.dhsspsni.gov.uk/ppi_public_consultation.pdf 5. Social Care Institute for Excellence (2008) Strengthening User Involvement in Northern Ireland: a Summary and Action Plan. London: Social Care Institute for Excellence. http://www.scie-socialcareonline.org.uk/profile.asp?guid=a47dc0de... Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care/Pharmacy Delivery and Implementation Partners Independent Sector Voluntary and Community Sector Patient and Client Council 156

Quality Dimensions Person-centred - Carers are recognised as real and equal partners in the delivery of care. Timeliness - Carers will be involved at all stages of planning, delivery and evaluation of services. Effectiveness - Involving carers in the planning, delivery and evaluation of services improves outcomes for the carer and cared for person. Equity - Carers irrespective of age, who they care for, or where they live will have the opportunity to be involved in the planning, delivery and evaluation of services. Performance Indicator 1. Trusts will have an action plan for carer involvement at all levels in their respective organisations. 2. The number of carers actively participating in commissioning, delivery and evaluation of services Data Source Health and Social Care Board reports re: Public and Personal Involvement Trust Audit Anticipated Performance Level Date to be achieved by 100% March 2015 (end of Year 1) and ongoing Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) and ongoing 157

SECTION 7 CONDITIONS MORE COMMON IN OLDER PEOPLE Overview of Conditions More Common in Older People These are the most medically orientated standards of the Framework and seek to maximise health gains for older people in the areas of Falls, Fractures, Incontinence, Delirium and Dementia. 1. Falls Screening within Primary Care: All older people will be offered annual and opportunistic case-finding checks in Primary Care to identify individuals at high risk of falling in the future. Identified individuals will be offered a multi-factorial, evidence based falls and bone health assessment and intervention to reduce the risk of future falls. 2. Falls Presenting to Intermediate or Secondary Care: All older people presenting to intermediate or secondary care because of a fall or with an injury resulting from a fall (i.e. fracture) will be offered a multi-factorial, evidence based falls and bone health assessment and intervention. 3. Hospital Care of Older People with a Fracture: All older people admitted to an inpatient fracture service should have routine access to acute orthogeriatric medical support from the time of admission. 4. Continence Services for Older People: Older people with continence difficulties should have an assessment carried out by a specialist continence health professional and, if appropriate, receive onward referral to an integrated continence service. 5. Recognition and Prevention of Delirium: All older people who have a major health crisis should be screened for delirium using a validated assessment tool such as the Confusional Assessment Scale shortened version (CAM). 6. Management of Delirium: All older people should receive a stepped-care approach to the management of delirium. A small minority of people with delirium may require specialist input, or may require to be cared for in a specialised environment. 158

7. End of Life Care Planning for Older People with Advanced Dementia. : Older people with Advanced Dementia are to be identified through existing Primary Care Dementia Registers. These individuals should have the Gold Standards Framework applied and have an Advance Care Plan drawn up as appropriate to inform appropriate End of Life Care. 8. Immobility: All older people who present to primary or secondary care with a sudden unexplained deterioration in their mobility should receive a Comprehensive Geriatric Assessment and access to re-enablement services as appropriate. 159

Standard 28: Falls Screening in Primary Care All older people will be offered annual and opportunistic case-finding checks in Primary Care to identify individuals at high risk of falling in the future. They will be offered a multi-factorial, evidence based falls and bone health assessment and intervention, to reduce risk of future falls. Rationale Falls are a frequent occurrence and have serious consequences for older people. Annually about a third of people aged over 65 years will fall. Up to half of these individuals will have recurrent falls. Falls can result in major physical harm including fractured bones, loss of independence and death. Less obviously, but importantly, psychological harm can also result. This may consist of loss of confidence, fear of falling, anxiety or depression. Falls or fear of falling is the most common reason people leave their own homes and move to long-term institutional care. Health and social care expenditure relating to falls is considerable. Approximately 5% of falls will result in fragility fracture (1-2% sustain a fracture of the femur and cost of treatment is approximately 28,000). If people who are at high risk of recurrent falls or fracture are identified and offered effective assessment and treatment, more than a third of falls will be prevented. People at high risk of falls in the future are people who have had more than 2 falls within 6 months or those with less frequent falls but who have a significant fear of falling. 160

Evidence 1. American Geriatric Society, British Geriatric Society, and American Academy of Orthopaedic Surgeons. (2001). Guidelines for the Prevention of Falls in Older People. Canadian Patient Safety Institute. 2. Close,J. et al. (1999) Prevention of Falls in the Elderly Trial (PROFET): A Randomised Controlled Trial. Lancet; 353: 93-9.7 3. Department of Health (2001) National Service Framework of Older People. London: Department of Health. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/ digitalasset/dh_4071283.pdf 4. Health Care Quality Improvement Partnership (2011) Falling Standards, Broken Promises. London: Royal College of Physicians. http://www.rcplondon.ac.uk/sites/default/files/national_report.pdf 5. Health Care Quality Improvement Partnership (2011) Falling Standards, Broken Promises. London: Royal College of Physicians. http://www.rcplondon.ac.uk/sites/default/files/national_report.pdf 6. National Institute for Clinical Excellence (2004) Clinical Practice Guidelines for the Assessment and Prevention of Falls in Older People. London: Royal College of Nursing. http://www.nice.org.uk/nicemedia/pdf/cg021fullguideline.pdf 7. National Patient Safety Agency. (2007) Slips, Trips and Falls in Hospital. The Third Report from the Patient Safety Observatory. London: National Patient Safety Agency. http://www.nrls.npsa.nhs.uk/easysiteweb/getresource.axd?assetid=60129... 8. Patient Safety First (2009) Reducing Harm from Falls Version 1. http://www.patientsafetyfirst.nhs.uk/ashx/asset.ashx?path=/interventionsupport/fallshow-to%20guide%20v4.pdf 161

Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Northern Ireland Ambulance Service Delivery and Implementation Partners Quality Dimensions Safety - Health care professionals will carry out assessment and treatment or exercise specialists who have sufficient skills and training to provide evidence based treatment. Timeliness - Case-finding will happen within 2 weeks of the index fall. Effectiveness - Case-finding of individuals at higher risk of future falls or fracture, offering evidence based assessment and individualised interventions will result in approximately 30% reduction in falls. Equity - Case-finding will ensure that the service is offered to everyone who may benefit. Patient-centred - The assessment and intervention is holistic and individualised. Performance Indicator 1. Staff assess the agreed range of factors which may cause a person to fall Data Source Trust Falls Coordinator Anticipated Performance Level 70% 80% Date to be achieved by March 2015 (end of Year 1) and ongoing March 2016 (end of Year 2) and ongoing 162 90% March 2017 (end of Year 3) and ongoing

2. Individuals identified as at high risk of falling are offered an intervention programme within 4 weeks of index fall Trust Falls Coordinator 70% 80% 90% March 2015 (end of Year 1) and ongoing March 2016 (end of Year 2) and ongoing March 2017 (end of Year 3) and ongoing 163

Standard 29: Falls Presenting to Intermediate or Secondary Care All Older People presenting to intermediate or secondary care because of a fall or with an injury resulting from a fall (i.e. fracture) will be offered a multi-factorial, evidence-based falls and bone health assessment and intervention. Rationale Falls can result in major physical harm including fracture, loss of independence and death. Health and social care expenditure relating to falls is considerable. Approximately 5% of falls will result in fragility fracture (1-2% sustain a fracture of the femur). If people who are at high risk of recurrent falls or fracture are identified and offered effective assessment and treatment, more than a third of falls will be prevented. The average cost of a fractured neck of femur is estimated as 28,000. Evidence 1. American Geriatric Society, British Geriatric Society, and American Academy of Orthopaedic Surgeons. (2001). Guidelines for the Prevention of Falls in Older People. Canadian Patient Safety Institute. 2. Close,J. et al. (1999) Prevention of Falls in the Elderly Trial (PROFET): A Randomised Controlled Trial. Lancet; 353: 93-97. 3. Department of Health (2001) National Service Framework for Older People. London: Department of Health. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents /digitalasset/dh_4071283.pdf 4. Gillespie, L.D. (2009) Interventions for Preventing Falls in Elderly People. The Cochrane Library /Wiley and Sons Ltd. http://www.mnfallsprevention.org/downloads/review-interventions-for-preventingfalls.pdf 164

5. Greater Glasgow NHS Strategy for Osteoporosis and Falls Prevention (2006) Glasgow: NHS Greater Glasgow and Clyde Health Board 6. Health Care Quality Improvement Partnership (2011) Falling Standards, Broken Promises. London: Royal College of Physicians. http://www.rcplondon.ac.uk/sites/default/files/national_report.pdf 7. National Institute for Clinical Excellence (2004) Clinical practice Guidelines for the Assessment and Prevention of Falls in Older People. London: Royal College of Nursing http://www.nice.org.uk/nicemedia/pdf/cg021fullguideline.pdf 8. National Patient Safety Agency. (2007) Slips, Trips and Falls in hospital. The Third Report from the Patient Safety Observatory. London: National Patient Safety Agency. www.nrls.npsa.nhs.uk/easysiteweb/getresource.axd?assetid=60129 9. Patient Safety First (2009) Reducing Harm from Falls Version 1. http://www.patientsafetyfirst.nhs.uk/ashx/asset.ashx?path=/interventionsupport/fallshow-to%20guide%20v4.pdf Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/Primary Care Northern Ireland Ambulance Service Delivery and Implementation Partners 165

Quality Dimensions Person-centred - The assessment and intervention is holistic and individualised. Safety - Health care professionals will carry out assessment and treatment or exercise specialists who have sufficient skills and training to provide evidence based treatment. Timeliness - Case-finding will happen within 2 weeks of the index fall. Effectiveness - Case-finding of individuals at higher risk of future falls or fracture, offering evidence based assessment and individualised interventions will result in approximately 30% reduction in falls. Equity - Case-finding will ensure that the service is offered to everyone who may benefit. Performance Indicator 1. Percentage of the total population of older people presenting to intermediate or secondary care because of a fall or with an injury resulting from a fall Data Source Trust Falls Coordinator Anticipated Performance Level Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 166

2. Older people presenting to intermediate or secondary care because of a fall are offered a multi factorial, evidence based falls and bone health assessment and intervention within 2 weeks of the index fall 3. Older people presenting to intermediate or secondary care because of a fall or with an injury resulting from a fall will be asked if they were offered a multi factorial, evidence based falls and bone health assessment and intervention within 2 weeks of the index fall Trust Falls Coordinator Patient and Client Council. 25% 50% 75% 25% 50% 75% March 2015 (end of Year 1) and ongoing March 2016 (end of Year 2) and ongoing March 2017 (end of Year 3) and ongoing March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 167

Standard 30: Hospital Care of Older People with a Fracture All older people admitted to an inpatient fracture service should have routine access to acute orthogeriatric medical support from the time of admission. Rationale Annually there are approximately 75,000 hip fractures in the UK and this is expected to rise to 101,000 by 2010 with associated costs of 2.2 billion. Older people admitted to fracture services (particularly people with a hip fracture) tend to be frail with significant co-morbidities. One in five people sustaining a hip fracture die within four months. Acute orthogeriatric involvement in both the pre and post-operative period is an essential component of good quality care, which has been shown to improve outcomes for this patient group. Evidence 1. British Orthopaedic Association and British Geriatric Society (2007) The Care of Patients with Fragility Fractures. http://www.bgs.org.uk/pdf_cms/pubs/blue%20book%20on%20fragility%20fracture%20care.pdf 7. Department of Health (2001) National Service Framework for Older People. London. http://www.dh.gov.uk/prod_consum_dh/groups/dh digitalassets/@dh/@en/ documents/digitalasset/dh_4071283.pdf 3. Health Care Quality Improvement Partnership (2011) Falling Standards, Broken Promises. London: Royal College of Physicians. http://www.rcplondon.ac.uk/sites/default/files/national_report.pdf 4. Institute for Innovation and Improvement (2006) Focus On: Fractured Neck of Femur Coventry: National Health Service Institute for Innovation and Improvement. http://www.institute.nhs.uk/images/documents/quality_and_value/focus_ On/DVQ_path_frac turefemurproof_nov.pdf 5. Murray, I et al (2011) Should Hip Fracture in a Frail Older Person be a Trigger for Assessment of Palliative Care Needs? British Medical Journal. 1:3-4. http://www.bmj.com. 168

6. Scottish Intercollegiate Guidelines Network (2009) Prevention and Management of Hip Fracture in Older People. http://www.sign.ac.uk/pdf/sign111.pdf Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs Delivery and Implementation Partners Quality Dimensions Patient-Centred - Acute orthogeriatric care should result in more patient centred care following individual assessment from an experienced clinician. Safety - A senior physician readily available at ward level will increase patient safety both directly and indirectly by increased training and supervision of all staff, enhanced medical care, better communication (with patients, families and other specialities) and optimal scheduling for theatre. Timeliness - By having orthogeriatric input from admission, discharge planning can begin at the earliest opportunity. Effectiveness - Patients should have better mortality and morbidity outcomes with acute orthogeriatric involvement on the fracture unit. A senior physician will be able to facilitate appropriate audit and research projects. Efficiency - Continuity of care will lead to less wastage and the duplication of effort that occurs by using a traditional on call medical service. Equity- Acute orthogeriatric care readily available in the fracture unit will ensure these patients will receive a level of medical care equal to that of similar patients (without fracture) admitted to the medical wards. 169

Performance Indicator 1. Health and Social Care Trusts providing inpatient fracture services have a designated Orthogeriatrician and provide shared care 2. Older people admitted with a fracture will have a specialist geriatric assessment within 72 hours Data Source Human Resource Departments Trust information systems Anticipated Performance Level Date to be achieved by 100% March 2015 (end of Year 1) 100% March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 170

Standard 31: Continence Services for Older People Older people with continence difficulties should have an assessment carried out by a specialist continence health professional and, if appropriate, receive onward referral to an integrated continence service. Rationale Continence problems are common and may lead to significant physical, psychological and social implications, causing, for example, skin breakdown, social embarrassment and strain on carers. The difficulties associated with dealing with incontinence are second only to dementia as a reason for an individual entering a care home due to the inability of carers to cope. Incontinence is a hidden problem and is not reported by at least 50% of those who are incontinent. It is also a common problem with 5-30% of community dwelling older people reporting urinary incontinence. Rates of people with continence problems in hospitals and nursing homes are reported to be over 50%. Those suffering incontinence report poor body image, often feeling dirty with a subsequent impact, for example, on work and personal relationships. National audit has repeatedly shown that vulnerable groups including frail older people receive a lower standard of care than a younger population. Treatments are available to improve/treat continence problems, both urinary and faecal, however, staff training is patchy and an element of ageism exists, as this problem may wrongly be accepted as a normal consequence of ageing. The use of costly containment products are not routinely guided by a continence assessment and management/treatment plan. In some cases, the problem is treatable and containment products are not required. 171

Evidence 1. Department of Health (2001) Good Practice in Continence Services. London. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents /digitalasset/dh_4057529.pdf 2. Department of Health (2001) Essence of Care: Patient Focussed Benchmarks for Clinical Governance. London. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents /digitalasset/dh_4127915.pdf 3. National Institute for Clinical Excellence (2006) Urinary Incontinence. London: National Institute for clinical excellence. http://www.nice.org.uk/nicemedia/pdf/word/cg40quickrefguide1006.pdf 4. Royal College of Physicians (2010) National Audit of Care. London: Royal College of Physicians. http://www.rcplondon.ac.uk/sites/default/files/full-organisational-and-clinical-reportnacc-2010.pdf Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/ Primary Care Delivery and Implementation Partners Quality Dimensions Person-centred - Engage with older people and their carers to inform the service development and ensure patient-focused outcome. Safety - Reduce incidence of complications associated with continence problems. Timeliness - Early intervention to improve quality of life and reduce incidence of complications by proactive case finding. 172

Effectiveness - All stakeholders should actively identify patients with urinary and faecal incontinence. A thorough assessment should be carried out to provide a diagnosis in all cases to inform effective management. Efficiency - All stakeholders should have a written policy document for continence promotion and incontinence management to include requirements for staff training in continence care and the development of an integrated care pathway. Equity - Information and services should be accessible to older people and their carers in a range of settings. Services for older people should be equitable to those for a younger population. Performance Indicator 1. Health and Social Care Trusts should have a lead health professional at a senior level responsible for delivery and development of an integrated continence service 2. Review of Health and Social Care Trusts written policy document for continence promotion and incontinence management Data Source Anticipated Performance Level Date to be achieved by Trust Report All Trusts March 2015 (end of Year 1) Trust Report All Trusts. Integrated Care Pathway Development. Integrated Care Pathway in place March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017(end of Year 3) 173

3. Number of older people who have received specialist assessment for continence issues Northern Ireland Single Assessment Tool Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) 4. Number of older people who have accessed the integrated continence service in each Trust Northern Ireland Single Assessment Tool Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 174

Standard 32: Recognition and Prevention of Delirium All older people who have a major health crisis should be screened for delirium using a validated assessment tool such as the Confusional Assessment Scale shortened version (CAM). Rationale Delirium is a sudden severe confusion and rapid changes in brain functions that occur with physical or mental illness. Currently delirium is under-diagnosed and under-treated. Its prevalence on medical wards in hospitals ranges from 10% to 31%, and 50% of people having surgery develop delirium. Adverse outcomes associated with delirium include: Longer stay in hospital; Increased incidence of dementia; Increase in hospital-acquired complications such as falls and pressure sores; Increase rate of admission to long-term care; and Increased mortality. The most important approach to the management of delirium is the identification and treatment of the underlying cause. US and UK guidelines recommend CAM for routine use as it can be completed in 5 minutes. When used by appropriately trained staff, specificity and sensitivity of over 90% can be reached. Evidence shows that comprehensive and structured training on delirium, applied to practice, reduces the incidence and duration of delirium. Evidence also shows that a dedicated resource is required to deliver training on an ongoing basis. This education and training role will be a key role for the Mental Health for Older People Liaison Service. 175

Evidence: 1. American Psychiatric Association (2010). Practice Guidelines for the Treatment of Patients with Delirium. Washington D.C./American Psychiatric Association. http://www.appi.org 2. Alzheimer s Society (2009): Counting the Cost: Caring for People with Dementia on Hospital Wards. London: Alzheimer s Society. http://www.alzheimers.org.uk/site/scripts/download.php?fileid=787 3. British Geriatrics Society and Royal College of Physicians (2006) The Prevention, Diagnosis and Management of Delirium in Older People. National Guidelines. In Concise Guidance to Good Practice No 6 London (UK) Royal College of Physicians. http://www.rcplondon.ac.uk/pubs 4. British Geriatric Society (2006) Clinical Guidelines for the Prevention, Diagnosis and Management of Delirium in Older People in Hospital. http://www.bookshop.rcplondon.ac.uk/contents/6be09b43-4f53-46ad-aa11-9bac401f3164.pdf 5. Chan D., Brennan, N. (1999). Delirium: Making the Diagnosis, Improving the Prognosis. Geriatrics, 54(3), 28-42. 6. Young, J. Inouye S.K. (2007) Delirium in Older People (2207). British Medical Journal 334: 842-846. 7. Inouye S. K., Schlesinger M. J., Lydon T. J. (1999) Delirium: A Symptom of How Hospital Care Is Failing Older Persons and a Window to Improve Quality of Hospital Care. New England Journal of Medicine: 106(5): 565-76. 8. National Institute of Clinical Excellence Guidelines. (2010) Delirium: diagnosis, prevention and management. http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf 9. Royal College of Psychiatrists (2005). Who Cares Wins: Improving the outcome for older people admitted to the general hospital. http://www.rcpsych.ac.uk/pdf/whocareswins.pdf 176

10. Siddiqi N, Holt R, Britton AM, Holmes J. (2007) Interventions for preventing delirium in hospitalised patients. Cochrane Database of Systematic Reviews. Issue 2. http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd009537/pdf Responsibility for Delivery / Implementation: HSCB PHA LCGs HSCTs GPs/ Primary Care Quality Dimensions: Delivery and Implementation Partners Independent Sector Safety - Patients who are at high risk of developing delirium will be identified at an earlier stage and receive more appropriate care thus reducing the occurrence of untoward incidents. Timeliness - Education and training will result in delirium being recognised at an earlier point so that a management plan can be devised to reduce the risk of harm to the patient. Patients who are at high risk of developing delirium will be identified at an earlier stage and will be targeted to receive preventative interventions. Effectiveness - Adverse outcomes should be reduced. Identifying those patients who are at high risk of developing delirium is critical to ensuring that they receive multi-component interventions. Efficiency - Counting the Costs Alzheimer s Society (2010) highlighted the savings that can be made by reducing length of hospital stay. Equity- By ensuring that staff within health and social care settings receives education and training on delirium then all patients should receive the same standard of care whatever the setting. Occurrence of delirium can be seen as a proxy measure of quality in-patient care. 177

Performance Indicator 1. Number of patients who develop Delirium in hospital 2. Reduced length of hospital stay for older people who develop Delirium 3. Each Health and Social Care Trust will have a Mental Health for Older People Liaison Service to coordinate and support the delivery of education and training to front line staff 4. Number of front line staff in Hospitals, domiciliary, residential and nursing homes who have participated in structured training re: assessment and management of delirium 5. Each Health and Social Care Trust will identify the incidence and prevalence of people who develop delirium Data Source Patient Administration System Patient Administration System Trust Self audit 100% Staff training records RQIA Anticipated Performance Level Establish baseline Performance level set once baseline is established Establish baseline Performance level set once baseline is established 20% 30% Trust self audit Establish baseline Date to be achieved by March 2015(end of Year 1) check March 2015(end of Year 1) check March 2015(end of Year 1) March 2016(end of Year 2) March 2017(end of Year 3) Annually Check 178

Standard 33: Management of Delirium All older people should receive a stepped-care approach to the management of delirium. A small minority of people with delirium may require specialist input, or may require to be cared for in a specialised environment. Rationale The majority of people with delirium should be managed by using non-pharmacological multi-faceted approaches supported by the Mental Health Liaison Service. A small minority of people with delirium may require the judicious use of pharmacological agents titrated slowly upwards to ensure that the minimum dosage is used. Pharmacological agents should not be prescribed unless the person with delirium is thought to represent a significant risk to him/herself, or others, or is acutely distressed. National research highlights the benefits of reduced reliance on potentially unnecessary drug treatment and the stepped-care approach to the management of people with delirium. This stepped-care approach can be achieved through education and training of nonspecialist staff. Evidence 1. British Geriatrics Society and Royal College of Physicians (2006) The Prevention, Diagnosis and Management of Delirium in Older People. National Guidelines. In Concise guidance to good practice No 6 London (UK) Royal College of Physicians. http://www.rcplondon.ac.uk/pubs 2. Banjeree, S. (2009) The Use of Antipsychotic Medication for People with Dementia: Time for Action. http://www.dh.gov.uk 3. National Institute of Clinical Excellence Guidelines. (2010) Delirium: Diagnosis, Prevention and Management. http://www.nice.org.uk 4. Siddiqi N, Holt R, Britton AM, Holmes J. (2007) Interventions for Preventing Delirium in Hospitalised Patients. Cochrane Database of Systematic Reviews. Issue 2. http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd009537/pdf 179

5. Young, J., Inouye, S, K. (2007) Delirium in Older People (2007). British Medical Journal 334:842-846. Responsibility for Delivery/ Implementation: HSCB PHA LCGs HSCTs GPs / Primary Care Quality Dimensions Delivery and Implementation Partners Independent Sector RQIA Person-centred - Non-pharmacological multifaceted interventions will be delivered in an individualised manner. If pharmacological treatment is required the dose will be tailored carefully to the individual s response. Safety - By implementing a multi-faceted non-pharmacological approach the use of anti-psychotic agents will be kept to a minimum reducing the serious side-effects from these medications. Timeliness - A stepped care model will allow for the most appropriate interventions to be given in a timely manner to ensure the most favourable outcome. Effectiveness - Drug treatments have been shown to prolong or aggravate delirium in some cases. By using a multi-faceted approach the prescription of anti-psychotic agents to treat delirium will be reduced. Efficiency - A multi-faceted approach to the management of delirium has been seen to be most effective. Equity - All patients with delirium will receive the same standard of treatment regardless of setting. 180

Performance Indicator 1. Reduction of institutional care as an outcome of an episode of delirium 2. Reduction in the use of neuroleptic and sedative drugs in the at risk population 3. Each Health and Social Care Trust will have a Mental Health for Older People Liaison Service to co-ordinate and support the delivery of education and training to front line staff in hospitals, domiciliary care, residential and nursing homes Data Source Patient Administration System GAIN audit Pharmacy records Staff Training Records Anticipated Performance Level Establish baseline Performance level set once baseline is established Establish baseline Performance level set once baseline is established 10% 20% 30% Date to be achieved by March 2015 (end of Year 1) March 2015(end of Year 1) M March 2015(end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 181

Standard 34: End of Life Care Planning for Older People with Advanced Dementia. Older people with Advanced Dementia should be identified through existing Primary Care Dementia Registers. These individuals should have the Gold Standards Framework prognostic indicators applied and where appropriate End of Life Care Plan should be agreed. Rationale Dementia is a progressive and ultimately terminal condition, and as such appropriate End of Life Care is best planned for in advance. An Advance Care Plan allows for timely discussion among those involved with the care of the individual with Advanced Dementia (including family and those advocating on behalf of the individual) of the level of medical and nursing intervention most appropriate at the end of this terminal illness when the individual lacks the mental capacity to take such decisions for him or herself. Often, acute illness occurs at night. In these situations, an on-call doctor may have to make a difficult decision about whether to admit the person to hospital. A decision to admit to hospital will often be made because of a lack of any prior knowledge of the individual with dementia, their stage of illness and the most appropriate approach to their care. This can lead to the distressing and relatively common situation where a person with advanced dementia is transferred to the acute hospital where they then die in unfamiliar surroundings. The presence of an Advance Care Plan for individuals with Advanced Dementia would inform the approach to their end of life care and give a framework for an End of Life Care approach most in keeping with that individual s best interest. The Gold Standards Framework prognostic indicators represent a systematic, evidence based but common-sense approach that provides health and social care professionals with a structure to identify those who are in the last year of life and, when used in conjunction with the End of Life Operational System helps deliver good quality care at the end of life. 182

An Advance Care Plan provides a structure for timely discussion of an end of life care approach most likely to meet the individual s needs. Evidence 1. Department of Health, Social Services and Public Safety (2010) Living Matters: Dying Matters. A Palliative and End of Life Care Strategy for Adults in Northern Ireland. http://www.dhsspsni.gov.uk/8555_palliative_final.pdf 2. General Medical Council (2010) Treatment and Care towards the End of Life: Good Practice in Decision-making. http://www.gmc-uk.org/end_of_life.pdf_32486688.pdf 3. National Gold Standard Service Framework (2006) Prognostic Indicator Guidance (version 2.25). http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/eolc-prognostic-indicatorguide.pdf 4. Royal College of Physicians (2009) Advance Care Planning: A National Guideline. http://bookshop.rcplondon.ac.uk/contents/pub267-e5ba7065-2385-49c9-a68ef64527c15f2a.pdf Responsibility for Delivery / Implementation HSCB PHA LCGs HSCTs GPs/ Primary Care Delivery and Implementation Partners 183

Quality Dimensions Person-centred - An Advance Care Plan allows for the delivery of a considered and fully individualised approach to the End of Life Care for people with Advanced Dementia. Effectiveness and Efficiency - This Standard uses resources already in development in Primary Care and seeks to prevent unnecessary and unhelpful hospital admissions for individuals with Advanced Dementia. Equitable - By locating this Standard in Primary Care it will be possible to identify up to 100% of individuals with Advanced Dementia. Performance Indicator 1. General Practitioners will identify older people with advanced dementia using Gold Standards Framework 2. General Practitioners will ensure that individuals who have been identified with advanced dementia have an advanced care plan within 3 months Data Source General Practitioners Dementia registers Quality and Outcomes Framework (QOF) Anticipated Performance Level Date to be achieved by 90% March 2015 (end of Year 1) 100% March 2016 (end of Year 2) 184

Standard 35: Immobility All older people who present to primary or secondary care with a sudden unexplained deterioration in their mobility should receive a Comprehensive Geriatric Assessment and access to re-enablement services as appropriate. Rationale Older people often have complex multi-system problems, are at increased risk for morbidity and mortality, and need comprehensive interventions that take into account the physical psychological and social components of health. Comprehensive geriatric assessment is an approach developed for this purpose. It is a process that determines an older person s medical, psycho-social, functional, and environmental resources and problems, and it creates an overall plan for treatment and follow-up. It encompasses linkage of medical and social care around medical diagnoses and decision-making under the leadership of a Doctor trained in geriatric medicine. Immobility is a common pathway by which a host of diseases and problems in older individuals produce further disability. Mobility issues are a major factor in a move to institutional care. Improvements in mobility or a reduction in the complications arising from immobility are almost always possible, even in those largely confined to bed. Relatively small improvements in mobility or active management strategies for immobility can decrease the incidence and severity of complications such as pressure sores, improving the patient s wellbeing and quality of life. Previous research suggests that assessment based interventions may result in additional costs initially. However, in the longer term comprehensive geriatric assessment not only improves patient outcomes they may also save costs by reducing hospital readmissions and lowering the need for long term institutional care. 185

Evidence 1. A Trial of Annual In-home Comprehensive Geriatric Assessments for Elderly People Living in the Community. Stuck AE, Aronow HU, Steiner A, Alessi CA, Büla CJ, Gold MN, et al. N Engl J Med 1995 ;333:1184 http://www.nejm.org/doi/full/10.1056/nejm199511023331805 2. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. Ellis G, Whitehead MA, Robinson D, O Neill D, Langhorne P. BMJ2011;343:d6553 http:// www.bmj.com/content/343/bmj.d6553 3. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Lancet1993;342:1032-6. http://www..ncbi.nlm.nih.gov/pubmed/8105269 Responsibility for Delivery/ Implementation: HSCB LCGs HSCTs Quality Dimensions Delivery and Implementation Partners RQIA Person-centred - Comprehensive Geriatric Assessment prior to permanent nursing home placement should help reduce unnecessary placement and optimise likelihood of older people continuing to live in their own homes. Efficiency - This Standard requires development and reconfiguration of existing resources but in longer term is expected to save costs by reducing hospital readmissions and lowering the need for long term nursing home care. Equitable - This standard targets older people living in the community and those admitted to secondary care settings. 186

Performance Indicator 1. Primary care and ED referral rates to Geriatric medicine of older people coded as off feet as primary problem Data Source Primary Care and Trust Patient Administration System Anticipated Performance Level Establish baseline 100% Date to be achieved by March 2015 (end of Year 1) March 2017 (end of Year 3) 2. Number of Comprehensive Geriatric Assessments delivered by Trust Trust Database Establish baseline Performance levels to be set once baseline is established March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 3. Percentage of older people entering institutional care who have received a Comprehensive Geriatric Assessment as part of the Single Assessment Tool prior to permanent placement Regulation and Quality Improvement Authority Establish baseline Performance levels to be set once baseline is established March 2015 end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 187

4. Incidence of pressure sores developed in secondary care settings IR1 Audit/SAI reports Establish Baseline Reduction in incidence of pressure sores by 30% from baseline March 2015 end of Year 1) March 2016 (end of Year 2) 5. Incidence of pressure sores developed in community care settings. Residential/Nur sing Homes Regulation and Quality Improvement Authority Reduction in incidence of pressure sores by 40% from baseline Establish baseline Reduction in incidence of pressure sores by 30% from baseline March 2017 (end of Year 3) March 2015 end of Year 1) March 2016 (end of Year 2) Reduction in incidence of pressure sores by 40% from baseline March 2017 (end of Year 3) 188

SECTION 8 MEDICINES MANAGEMENT Overview of Medicines Management Standards Introduction: Ageing is associated with a greater burden of disease and the use of associated medicines. Prescribing is the most common medical intervention experienced by older people and the concurrent use of multiple medicines is common. It is important to have good medicines management systems in place across all healthcare settings to ensure that older people receive the right medicines at the right dose in the right form. Medicines prescribed in accordance with local national guidelines offer assurance of high quality care and maximum health gains from medicines. In addition, in order to encourage concordance with medicines, older people and their carers should have an opportunity to participate in decision-making about their treatment. Compiling and keeping accurate records of medicines taken reduces the risk of errors especially when older people are transferring from one care setting to another. Regular review(s) of all medicines taken ensures that all medicines taken by older people remain appropriate, safe and effective in the longer term and minimises waste. The Framework includes two standards relating to medicines management: 1. Medicines Management: In partnership with healthcare professionals, older people should be provided with appropriate, safe and effective medicines and support to enable them to gain maximum benefits from medicines to maintain or increase their quality and duration of life. 2. Medicines Review: Older people should have a systematic review of all their medicines at appropriate intervals along the patient pathway to ensure that their medicines continue to be appropriate and that they are participative in the treatment as prescribed. 189

Standard 36: Medicines Management In partnership with healthcare professionals, older people should be provided with appropriate, safe and effective medicines and support to enable them to gain maximum benefits from medicines to maintain or increase their quality and duration of life. Rationale Medicines management processes for older people should ensure that the right person receives the right medicine in the right dose in the right formulation at the right time. Older people should be provided with medicine that is prescribed in accordance with local and national guidelines offering assurance of high quality of care. Good documentation of prescribing decisions, recording of reported side-effects and an assessment of whether medicine has been effective is necessary to ensure safe and effective care. As people age, their use of medicines increases due to the development of long-term medical conditions and more preventative prescribing. When used appropriately, medicines can improve both functioning and quality of life. Demographic changes mean that prescribing for older people is becoming an increasingly important aspect of clinical care. In the UK, 45% of prescriptions are dispensed to patients over the age of 65 years. Four in five people over 75 take at least one prescribed medicine, with 36% taking four or more medicines. Research shows that around 50% of medicines for long-term conditions are not taken as prescribed and that people s beliefs and preferences about medicines are the most important factor in how they use them. All health and social care professionals who prescribe medicines should work with the support and advice of appropriately trained pharmacists. They should provide support for older people taking medicines through a partnership approach between themselves, older people and their associated carers. informed decision about their medication and encourages concordance with the agreed treatment plan. 190

Partnership working should mean an informed dialogue takes place about the choice of medicine. This enables older people to make an Evidence 1. Department of Health (2005). The National Service Framework for Long Term Conditions. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents /digitalasset/dh_4105369.pdf 2. Department of Health (2001). Medicines and Older People: Implementing Medicines-related Aspects of the National Service Framework for Older People. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents /digitalasset/dh_4067247.pdf 3. Health Survey for England 1998. Volume 1: Findings. 4. National Service Framework for Older People in Wales. (2006). http://wales.gov.uk/docs/dhss/publications/060320nationalserviceframeworkforolderpe opleen.pdf 5. Pharmaceutical Society of Australia (2010). Professional Practice Standards. Version 4. http://www.psa.org.au/download/standards/professional-practice-standards-v4.pdf 6. Patient.co.uk. Prescribing for the Older Patient. http://www.patient.co.uk/doctor/prescribing-for-the-older-patient.htm 7. Sabate E. (2003). Adherence to Long-term Therapies: Evidence for Action. Switzerland: World Health Organisation. 8. Stevenson F. The Patient s Perspective. (2004). In: Bond C, editor. Concordance, a Partnership in Medicine Taking. Pharmaceutical Press. 9. Wynne H A, Blagburn J. Drug treatment in an ageing population: practical implications. Maturitas. 2010; 66(3): 246-50. 191

Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/ Primary Care/ Community Pharmacists Delivery and Implementation Partners Quality Dimensions Person-centred - The provision of medicines to older people should be based on what is important to them as individuals, what has worked in the past and what hasn t worked for them. Older people and their carers should be active partners in decisions about medicine prescribed for them. Safety - The right medicine in the right dose in the right formulation at the right time for the individual minimises the risk of adverse side effects. Medicines should be prescribed, administered and monitored in accordance with local and national guidelines. Timeliness - Timely access to appropriate treatment promotes recovery. Efficiency / Effectiveness - Prescribing decisions should be evidence-based and in accordance with local and national guidance where available. Individual prescribing decisions must be recorded. Properly managed, prescribed medication can improve quality of life. 192

Performance Indicator 1. Level of prescribing in concordance with local medicines formulary and national standards Data Source HSC Trusts / Business Services Organisation s prescribing Database Anticipated Performance Level 70% Ongoing in tandem with development of the NI formulary Date to be achieved by March 2015 end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 2. Satisfaction reported by people and their carers about medicines information, support for decision making and quality of life 3. Proportion of people with long term conditions accessing a specific medicines management support programme for concordance 4. Number of older people with medicines related admissions or readmissions to hospital User and carer feedback HSCB (community pharmacy contract) Trusts (selfadministration of medicines) Case note audit Establish baseline Performance levels to be determined once baseline established. Establish baseline Performance levels to be determined once baseline established Establish baseline Performance levels to be determined once baseline established March 2015 end of Year 1) March 2015 end of Year 1) March 2017 (end of Year 3) 193

Standard 37: Medicines Review Older people should have a systematic review of all their medicines at appropriate intervals along the patient pathway to ensure that their medicines continue to be appropriate, and that they participate in the treatment as prescribed. Rationale Ageing is associated with a greater burden of disease and the use of associated medicines. Amongst older people the concurrent use of multiple medicines is common and often causes problems through drug interactions. There may also be instances where appropriate medicines are under-used. Older people are often those at highest risk of significant morbidity or mortality and therefore are most likely to benefit from preventative medicines. However, due to the physical consequences of ageing, older people may also be at highest risk of adverse drug events. Regular medicines review ensures that older people receive appropriate medicines and minimises waste. When older people move across care settings there is a risk of medication errors due to inaccuracies in the medicines list. It is essential that every time an older person moves to another care setting, accurate and reliable information about their medicines be transferred at the same time. Errors in taking medicines are one of the leading causes of the admission of older people to hospital. Medication records are kept in a variety of formats in a variety of settings and are not easily shared. Therefore any individual record will only be as accurate as the last update and may not reflect all the medicines that a person is taking. A medicines review is best performed once an accurate list of medicines has been compiled. A medicines review encompasses a continuum of processes in various formats and complexities ranging from an opportunistic discussion between the healthcare professional and an older person to a prescriber carrying out a more comprehensive and proactive approach to reviewing medicines. 194

Different approaches are taken in practice for different purposes. Prescribers conducting face-to-face clinical medicines reviews with patients should include all medicines prescribed or bought over the counter, seek the older person s (or their carer s) consent to any changes made and aim to achieve concordance about medicinestaking. The outcome of the review should be documented in the older person s notes and the impact of any changes should be monitored. Evidence 1. Clyne.W, Blenkinsopp.A, Seal.R. (2008) National Prescribing Centre. A Guide to Medication Review. Liverpool: National Prescribing Centre. http://www.npc.nhs.uk/review_medicines/intro/resources/agtmr_web1.pdf 2. Institute for Healthcare Improvement (2011). Innovation at Its Best: Medication Reconciliation. http://www.ihi.org/knowledge/pages/improvementstories/innovationatitsbestmedrec 3. National Collaborative Medicines Management Services Programme (2002). Briefing: Room for Review. A Summary Guide To Medication Review: The Agenda For Patients, Practitioners And Managers. Task Force On Medicines Partnership. http://www.keele.ac.uk/pharmacy/npcplus/medicinespartnershipprogramme/additionalr esources/roomforreviewimpactevaluation/rfr_eval1.pdf 4. National Prescribing Centre (2008). Medicines Reconciliation: Guide to Implementation. http://www.npc.nhs.uk/improving_safety/medicines_reconciliation/resources/reconcilia tion_guide.pdf 5. Pharmaceutical Society of Australia (2010). Professional Practice Standards. Version 4. http://www.psa.org.au/download/standards/professional-practice-standards-v4.pdf Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/ Primary Care/ Community Pharmacists Delivery and Implementation Partners 195

Quality Dimensions Person-centred - People should be active partners in decisions about medicine prescribed for them. Safety - Medicines review has numerous potential benefits for older people including improving the current and future management of their medical condition, improving health outcomes through optimal medication, reduction in adverse effects and reduction in unwanted or unused medicines. Timeliness - Prescription of the right medicine at the right time improves the current and future management of their medical condition. Efficiency / Effectiveness - The right medicine for an individual improves their health outcome, reduces adverse effects and reduces unwanted and unused medicine. Performance Indicator 1. Percentage of older people receiving four or more medicines who are offered a medicines review annually Data Source GP records QOF Pharmacist records Anticipated Performance Level 80% 80% 80% Date to be achieved by March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 2. Percentage of older people residing in care homes receiving a face- to-face clinical medicines review annually GP records HSCB report Establish baseline Performance levels to be determined once baseline established March 2015 (end of Year 1) 196

3. Percentage of older people in secondary care who have had their medicines list checked and verified as accurate on admission HSC Trusts Audit Establish baseline Performance levels to be determined once baseline established March 2016 (end of Year 2) 4. Review of regional minimum data set arrangements for medicinesrelated information for use when older people move across care settings is agreed HSCB report Progress of arrangements Arrangements completed March 2016 (end of Year 2) March 2017 (end of Year 3) 5. Medicines with highest risk for older people are monitored appropriately in accordance with local guidance GP records GAIN audit Establish baseline Performance levels to be determined once baseline established March 2016 (end of Year 2) March 2017 (end of Year 3) 197

SECTION 9 - TRANSITIONS OF CARE Overview of Transitions of Care 1. Single Access Point for Information and Services: Older people should be able to access to a single point of contact for information and advice about all aspects of community support, health and social care services when older people first require help to maintain their independence. 2. Reablement to Maintain Independence: Older people should be offered a period of intensive re-ablement to regain their optimum level of independence and confidence before any assessment is made for longer term supports. 3. Early Identification to Maximise Independence: Older people with health problems should be identified early to maximise independence and reduce crisis. Treatment and care should be delivered in the most appropriate setting. 4. Increased Awareness of the Needs in General Hospitals: Older people with complex needs should be screened and appropriately managed by specialist staff during episodes of general hospital care. 5. Improved Access to Assessment and Rehabilitation: Older people with complex needs including dementia or mental health needs should be offered comprehensive, specialist assessments and a period of rehabilitation before consideration is given to the need for long term care. 6. Specialist Support in Nursing Homes: Older people in nursing homes should be able to access appropriate medical and other specialist supports to ensure their needs are met safely and effectively, including palliative care and End of Life Care planning. 7. Person-centered Palliative and End of Life Care: All older people identified to have End of Life Care needs should have a key worker and access to effective palliative and supportive care services for end of life needs. 8. Palliative and End of Life Care (Generic Standard): All people with advanced progressive incurable conditions, in conjunction with 198

their carers, should be supported to have their end of life care needs expressed and to die in their preferred place of care. 9. Improved Dementia and Mental Health Services: Older people with mental health conditions or dementia should, from an early stage, access services and environments that provide skilled assessment, treatment and care and maintain as much independence as possible. 199

Standard 38: Single Access Point for Information and Services Older people should be able to access a single point of contact for information and advice about all aspects of community support and health and social care services when they first start to need help to maintain their independence. Rationale Older people want and value that little bit of help. This is low level support that promotes health, wellbeing and quality of life in the older person s own home. They should be able to live as independently as possible within their local communities with easy access to a varied network of supports which they have the opportunity to shape and develop. However, it is evident that information about the range and accessibility of low level services is not always easily available, and in accessible formats, when an older person needs it and referrals to health and social care services are often made. Across Northern Ireland thousands of such referrals are made each year. Some can result in the provision of services which promote dependency and commit resources unnecessarily. It is important that there is a move away from thinking about conventional social care services towards thinking about the assistance that older people need to enable them to maintain their chosen lifestyle. The quality of outcomes for older people can be improved when there is a more comprehensive understanding of all the local services and supports that are available and the referral process is managed by a system which integrates the knowledge of local community networks and health and social care services. Local services need to include the local community and voluntary sector services, statutory services and effective links with relevant agencies such as housing and social security bodies. Access to good quality information about the range of supports should result in timely provision of information and a faster resolution of the older person s concerns/needs. 200

Evidence 1. Allen, Kerry and Glasby, Jon (2010) The Billion Dollar Question: Embedding Prevention in Older People s Services - 10 High Impact Changes. Discussion Paper. University of Birmingham, Health Services Management Centre. http://epapers.bham.ac.uk/759/1/policy%2dpaper%2deight.pdf 2. Lewis, H. Fletcher, P. Hardy, B.; Milne, A. and Waddington, E. (1999) Promoting Wellbeing: Developing a Preventive Approach with Older People. Leeds: Nuffield Institute for Health. 3. Lis, K. Reichert, M. Cosack, A. Billings, J. and Brown, P. (Ed.) (2008). Evidence-Based Guidelines on Health Promotion for Older People. Austrian Red Cross, Vienna. http://www.healthproelderly.com/pdf/hpe-guidelines_online.pdf 4. National Health Service (2006) Inquiry into Mental Health and Well-Being. http://www.healthscotland.com/topics/stages/healthy-ageing/mental-health-laterlife.aspx 5. National Institute for Health and Clinical Excellence (2008) Public Health Guidance: Occupational Therapy Interventions and Physical Activity Interventions to Promote the Mental Wellbeing of Older People in Primary Care and Residential Care. http://www.nice.org.uk/nicemedia/pdf/ph16guidance.pdf 6. Raynes, N. Beecham,J. and Clark,H. (2006) Evidence Submitted to the Older People's Inquiry into 'That Bit of Help'. Volume II. Joseph Rowntree Foundation, York Publishing Service. http://www.jrf.org.uk/sites/files/jrf/9781859355022.pdf 7. Walters.R, Cattan.M, Speller.V,and Stuckelberger.A. (2000) Proven Strategies to Improve Older People's Health: a Eurolink Age Report for the European Commission. London: Eurolink Age. 8. Welsh Assembly Government (2006) National Service Framework for Older People in Wales. http://wales.gov.uk/docs/dhss/publications/060320nationalserviceframeworkforolderpe ople 201

Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/ Primary Care Delivery and Implementation Partners Voluntary and Community Sector Independent Sector Northern Ireland Housing Executive Quality Dimensions Person-centred - Ensure that older people are treated with the utmost respect and dignity to remain in control and independent. Safety - Ensure that older people get access to quality information to enable them to resolve their concerns/difficulties at point of contact where possible or they are referred to Trust services if necessary. Effectiveness - Partnership working between the community, voluntary and statutory services at local level. Equity - Ensure that there is easy access to information and services for everyone. Performance Indicator 1. Number of older people who have accessed the single point of contact & what information, or community support provided 2. Number of older people who have accessed the single point of contact and required onward referral to health and social care services Data Source Anticipated Performance Level Monitoring System for single point of contact in each Trust Monitoring System for single point of contact in each Trust Establish baseline Performance level set once baseline is established Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) March 2015 (end of Year 1) 202

Standard 39: Re-ablement to Maintain Independence Older people should be offered a period of re-ablement to regain their optimum level of independence and confidence before any assessment is made for longer term supports. Rationale Evidence shows that timely and short-term periods of social care re-ablement, focusing on skills for daily living, can help people to live more independently and reduce their need for ongoing homecare support. Re-ablement should be part of a continuum of community based prevention services focussed on: supporting service users to regain confidence and re-learn selfcare skills so that their need for longer term support is reduced; ensuring older people have an opportunity to maximise their independence and remain integrated in community networks; ensuring effective use of resources to meet the needs of users now and in the future. Re-ablement is a whole systems approach to embed the concept and practice of preventing loss of independence where possible and ensuring that services have this goal at the centre of their purpose and philosophy. Social care services in all sectors should ensure a re-ablement ethos is evidenced in the outcomes for their service users. Increased partnership working with the community and voluntary sectors to maximise opportunities for older people to remain connected to communities and access to low level services are essential components of re-ablement. All older people whose needs indicate that they have become more dependent should receive a re-ablement service prior to increasing their long-term care package. Recent evidence from a longitudinal study of the approach found in three schemes that 53% to 68% of those referred left re-ablement requiring no immediate homecare package and 36% to 48% continued to require no homecare package two years later. 203

Evidence 1.Department of Health (June 2007). Access Management: Full Release Initiative Care Services Efficiency Delivery (CSED). http://www.csed.dh.gov.uk/_library/resources/csed/access_mgmt.pdf 2. Department of Health (November 2007). Homecare Re-ablement Work stream Retrospective Longitudinal Study. Version HRA006. Care Services Efficiency Delivery (CSED). http://www.csed.dh.gov.uk/_oldcsedassets/longit-study-bc.pdf 3. Department of Health (November 2010). Prospective Longitudinal Study: The Short-term Outcomes and Costs of Reablement Services, Care Services Efficiency Delivery (CSED). http://www.csed.dh.gov.uk/asset.cfm?aid=6672 4. Francis,J. Fisher,M. and Rutter,D. (2011) Re-ablement: a Cost- Effective Route to Better Outcomes. Paper 36. London: Social Care Institute for Excellence. http://www.scie.org.uk/publications/briefings/files/briefing36.pdf 5. Jones, K. Baxter, K. Curtis, L. Arksey, H. Glendinning,C. and Rabiee, P. (2009). The Short-term Outcomes of Home Care Reablement Services: Interim Report. York/Canterbury: Social Policy Research Unit/ Personal Social Services Research Unit. 6. Rabiee, P. Glendinning, C. Arksey, H. and Baxter, K. (2009) Investigating the Longer Term Impact of Home Care Re-ablement Services. York/Canterbury: Social Policy Research Unit/ Personal Social Services Research Unit. http://www.york.ac.uk/inst/spru/research/summs/reablement2.php 7. Wanless, D and Forder, J. (2006) Social Care Review: Securing Good Social Care for Older People. Personal Social Services Research Unit: London School of Economics and Kings Fund. http://www.kingsfund.org.uk/current_projects/wanless_social_care_review/ 204

Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/ Primary Care Quality Dimensions Delivery and Implementation Partners Voluntary and Community Sector Independent Sector Northern Ireland Housing Executive Person-centred - Ensure that the most enabling care package is established to ensure that an individual has the opportunity to be as independent and fulfilled as possible in all aspects of their life. Timeliness - Ensure that older people whose needs are increasing access a re-ablement service prior to assessment for longer term services. Efficiency and Effectiveness - Ensure that all older people have an opportunity to achieve maximum independence before resources are committed. Performance Indicator 1. Number of older people who no longer require a home care service after a period of reablement Data Source Trust Report Anticipated Performance Level Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) 2. Number of older people who still need a home care service after a period of re-ablement 3. The number of weekly care package hours at the end of re-ablement Trust Report Trust Report Establish baseline Performance level set once baseline is established Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) March 2015 (end of Year 1) 205

Standard 40: Early Identification to Maximise Independence Older people with health problems should be identified early to maximise independence and reduce crisis. Treatment and care should be delivered in the most appropriate setting. Rationale Older people should always access high quality secondary care services when required. However many emergency admissions to hospital could be avoided by more timely intervention and support in the community which is better for older people and reduces unnecessary pressure on hospitals. In addition many patients remain in hospital unnecessarily because they are waiting for equipment or community care service It has been shown that more individualised, flexible and responsive care for older people can help maximise their independence. There should be a change in patterns of investment to more home and community based services in the future. Such services may include: a specialist multidisciplinary service providing single point of access to assessment, treatment and care at home with pathways to essential community back-up services such as diagnostics, social care, falls services and intermediate care; a co-ordinated crisis response available on a 24 hour basis and which can help prevent unnecessary hospital or care home admission; better access to community equipment; well integrated primary and community care services which facilitate assessment and planning outside hospital. 206

Evidence 1. British Geriatrics Society England Council Report 2004. The Challenge of Consultant Geriatric Medicine in England. London: British Geriatrics Society. 2. Elder, A. Can we Manage More Acutely III Elderly Patients in the Community? Age Ageing 2001; 30 : 441-443. 3. Gray L/ (2007) Geriatric consultation: is there a future? Age Ageing; 36(1): 1-2. 4. National Health Institute (2006). Delivering Quality and Value. Directory of Emergency Ambulatory Care for Adults. http://www.necvn.nhs.uk/uploadedfiles/content/chd/documents/hf%20- %20Directory%20of%20Ambulatory%20Emergency%20Care%20for%20Adults%20- %20March%202010.pdf 5. Royal College of Physicians (2007). Acute Medical Care the Right Person, in the Right Setting First Time. Report of the Acute Medicine Task Force. London: Royal College of Physicians. http://bookshop.rcplondon.ac.uk/details.aspx?e=235 6.Royal College of Physicians of London (2007) National Clinical Audit of Falls of Bone Health in Older People Report. London: Royal College of Physicians. http://www.bgs.org.uk/index.php?option=com_content&view=article&id=337:nationalb onesaudit&catid=47:fallsandbones&itemid=307 7. Royal College of Physicians of London Working Party Report (2000). Management of the Older Medical Patient : Teamwork in the Journey of Care The Interface between General (internal) Medicine and Geriatric Medicine. London Royal College of Physicians. http://bookshop.rcplondon.ac.uk/details.aspx?e=195 8. Royal College of Physicians (1994). Ensuring Equity and Quality of Care for Elderly People. London : Royal College of Physicians. http://www.journals.cambridge.org/action/displayabstract?frompage=online&aid= 2019420 207

9. Stuck, A.E. Siu, A.L., Wieland, G.D. Rubenstein, L.Z, Adams P. (1993) Comprehensive Geriatric Assessment : A Meta-analysis of Controlled Trials. Lancet; 342: 1032-6. 10. Thomas, A. et al (1994) In Acute Medicine; The Integrated Model; The Age-defined Model; The Traditional Model. Age and Ageing; 23: S22-7. 11. Young JB, Robinson J, Dickenson E. (1998).Rehabilitation for Older People. British Medical Journal; 316: 1108-9. Responsibility for Delivery/ Delivery and Implementation Implementation Partners HSCB Voluntary and Community PHA Sector LCGs Independent Sector HSCTs Northern Ireland Housing GPs/ Community Executive Pharmacy/Primary Care Quality Dimensions Person-centred - Rehabilitation plans will be based on the service user s personal goals. Safety - People will be offered the right service to meet their needs and ensure their independence. Timeliness - People getting the right support at the right time will bring positive benefits in the longer term. Effectiveness and Efficiency - Availability of a comprehensive, flexible range of services developed to meet the assessed needs of the local population will reduce reliance on acute hospitals and institutional care and improve independence and wellbeing. Equity - Everyone has equal access to a range of support services. 208

Performance Indicator 1. Number of older people receiving urgent care at home 2. Outcomes for older people receiving urgent care at home Data Source Anticipated Performance Level Trust Report Establish baseline Date to be achieved by March 2016 (end of Year 2) Performance level set once baseline is established Trust Report 100% March 2016 (end of Year 2) 209

Standard 41: Increased Awareness of Needs in General Hospitals Older people with complex needs should be screened and appropriately managed by specialist staff during episodes of general hospital care. Rationale Older people admitted to an in-patient bed in a general hospital often have complex needs that are not identified. These may include clinical problems such as delirium, malnutrition, dementia, mobility problems, incontinence and social factors such as isolation, inappropriate housing and social deprivation. Where identified, these are not always appropriately assessed and managed and this can lead to the premature commitment to permanent high dependency care. This reduces a person s independence and increases overall health and care costs. Older persons should be screened promptly after admission to identify those with complex needs. They should have a multidisciplinary needs assessment carried out by a team with specialist medical input, and have access to a range of rehabilitation and re-ablement services. Information from General Practitioners should be included in the assessment process. Community staff should be identified and involved after admission to ensure discharge planning is initiated at an early stage. Evidence shows that older persons with complex needs are vulnerable on discharge from acute settings. They should have a discharge plan which is individualised, person-centred and reviewed to ensure a seamless transition with services provided to meet their ongoing health and social care needs and to enable them to maximise their potential on discharge. 210

Particular issues include the availability of suitable and timely transport, provision of discharge medications in an appropriate way, proper documentation of the transfer, inter-professional communication (in particular with the General Practitioner), and communication with the patient and family or carers. It is essential that community key workers are involved from the outset to lead on discharge planning. Evidence 1. Academy of Medical Royal Colleges (2008) A Clinician s Guide to Record Standards - Part 2. http://www.aomrc.org.uk/.../216-a-clinicians-guide-to-record-standards-part-2.html 2. Department of Health, Social Services and Public Safety (2010) Carer and Discharge Guidance- Guides for Carers, Staff and Managers/Policy Makers. http://www.dhsspsni.gov.uk/eccu3-2010.pdf 3. Ellis, G., Langhorne, P. (2004) Comprehensive Geriatric Assessment for Older Hospital Patients. British Medical Bulletin Vol.71.No.1. Oxford University Press. 4. Harari, D. Martin, FC. Buttery, A. O'Neill S, and Hopper A (2007) The Older Persons' Assessment and Liaison Team 'OPAL': Evaluation of Comprehensive Geriatric Assessment in Acute Medical Inpatients, Age and Ageing, 36(6):670-5. http://knowledgetranslation.ca/sysrev/articles/project51/harari2007.pdf 5. Parker, S.G. et al. (2002) A Systematic Review of Discharge Arrangements for Older People. Health Technology Assessment Volume 6 Number 4. The National Coordinating Centre for Health Technology Assessments. http://www.hta.ac.uk/fullmono/mon604.pdf 6. Shepperd, S. Parked, J. McClaran, J. Phillips, C. (2004) Discharge Planning from Hospital to Home. London: The Cochrane Database of Systematic Reviews. 211

Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/ Community Pharmacy/Primary Care NIAS Delivery and Implementation Partners Voluntary and Community Sector Independent Sector Northern Ireland Housing Executive Quality Dimensions Person-centred - All older patients with complex needs will have an individual discharge plan focussed on their particular needs. Safety - Patients with complex needs should be identified, assessed and managed in a way, which minimises risk to the older person while promoting their independence. Timeliness - Early identification of need will ensure more timely intervention. Timing of discharge from hospital will be aligned with the needs of the patient. Effectiveness - Proper planned discharge arrangements will avoid inappropriate or untimely discharge, thus improving outcomes for patients. Efficiency - Using community resources better, improved planning and coordination will result in more timely and better discharge planning for older persons with complex needs. This will reduce a person s length of hospital stay (and increase the use of hospital beds). Equity - All older patients with complex needs will have individual discharge plans focussed on their particular needs. This will ensure equity of care provision. 212

Performance Indicator 1. Reducing length of hospital stay for older persons with complex needs 2. Percentage of older persons admitted directly to care homes (for the 1 st time from a general hospital) Data Source Patient Administration System return Patient Administration System return Anticipated Performance Level Establish baseline Performance level set once baseline is established Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) March 2015 (end of Year 1) 3. There is a documented discharge plan for each older person with complex needs discharged from a General Hospital, including details of communication with the patient, his/her family/carer and professionals outside hospital Audit Establish baseline Performance level set once baseline is established March 2015 (end of Year 1) 213

Standard 42: Improved Access to Assessment and Rehabilitation Older people with complex health needs including people with dementia or mental health needs should be offered comprehensive, specialist assessments and a period of rehabilitation before consideration is given to the need for long term care. Rationale Regionally we continue to have an over reliance on institutional models of care however the majority of older people want to remain in their own home. A number of reports have highlighted that the use of residential and nursing home care in Northern Ireland is higher than elsewhere in the UK. There is robust evidence to demonstrate that comprehensive specialist assessments, when followed by the implementation of individual rehabilitation reduces the risk of older people being readmitted to hospitals or placed in care homes. It also improves their survival rates and their physical and cognitive functioning. It is essential that assessments include, where appropriate access to specialist sensory assessments and support. Comprehensive, specialist assessments, treatment and rehabilitation should be available in a range of settings in community hospitals, health and wellbeing centres and in general hospitals. These specialist assessments will record decisions on a person s care and support needs within the Framework defined in the Northern Ireland Single Assessment Tool to ensure a consistent, comprehensive approach. Evidence 1. British Geriatric Society (1999) Response to Royal Commission on Long Term Care for the Elderly. Select Committee on Health Minutes of Evidence. http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/399/5031016. 2. Kane. R L, Keckhafer. G, Flood. S, et al (2003) The Effect of Evercare on Hospital Use. Journal of the American Geriatrics Society 51 (10), 1427-1434. http://onlinelibrary.wiley.com 214

3. Marshall, M. (2005) Perspectives on Rehabilitation and Dementia. London: Jessica Kingsley Publishers. 4. Stevenson, J. (1999) Comprehensive Assessment of Older People. London: King s Fund; Pavillion Publishing. 5. Howe, A. (1997) Health Care Costs to the Ageing Population: The Case of Australia. Review in Clinical Gerontology. 6. Young,J. and Sykes, A. (2005) The Evidence Base for Intermediate Care. CME Geriatric Medicine; 7(3): 117-125 Responsibility for Delivery/ Delivery and Implementation Implementation Partners HSCB Voluntary and Community PHA Sector LCGs Independent Sector HSCTs Northern Ireland Housing GPs/ Community Executive Pharmacy/Primary Care Housing Associations Quality Dimensions Person-centred - All plans will respond to the assessed needs and wishes of the person. Safety - This standard will ensure that older people with complex needs can access the appropriate comprehensive, specialist person-centred assessment, treatment and support. Timeliness - Providing this intervention at times of care transitions including when consideration is being given to admission to care home or intensive home care package. Effectiveness - Timely access to comprehensive, specialist and person-centred assessments followed by an individualised care plan will improve independence and quality of life. Efficiency - Access to comprehensive, specialist and personcentred assessments and follow-up rehabilitation/re-ablement packages will prevent or delay access to more costly long-term care packages. 215

Equity - All older people with complex needs will have access to comprehensive, person-centred assessments and follow up Plans. Performance Indicator 1. Number of people with a comprehensive, person-centred, specialist assessment 2. Number of older people who accessed rehabilitation programmes 3. Number of older people who had a comprehensive, person-centred, specialist assessment and period of rehabilitation with the following outcomesa. returned home with no care package b. returned home with a care package (please specify number of hours of domiciliary support) c. returned to care home d. admitted to care home for the first time Data Source Audit Community information systems NISAT Audit Audit NISAT Anticipated Performance Level Establish baseline Performance level set once baseline is established Establish baseline Performance level set once baseline is established. Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) March 2015 (end of Year 1) March 2015 (end of Year 1) 216

Standard 43: Specialist Support In Nursing Homes Older people who live in nursing homes should be able to access appropriate medical and other specialist supports to ensure their needs are met safely, effectively including palliative care and end of life care planning. Rationale Nursing homes provide care for very frail and vulnerable older people. Homes should have access to advice and support from relevant specialists to meet the assessed needs of residents. Recent survey information suggests that 70% of care home residents do not get a planned medical review by their GP and 44% are not getting a regular planned review of their medication. The nursing home sector is also increasingly providing short-term services to facilitate hospital discharge and is working in partnership with Trusts. In this changing care environment it is necessary to ensure that appropriate specialist support is provided in a coordinated way in order to reduce readmission to hospitals and to ensure that people s complex needs are recognised and managed.links should be made between palliative/end of life and dementia services to identify and respond appropriately to individual needs. Evidence 1. Age Concern (2006) Hungry to be Heard. England: Age Concern. http://www.ageuk.org.uk/documents/en- GB/ID9489%20HTBH%20Report%2028ppA4.pdf?dtrk=true 2. Barry, P.J. et al (2006). Inappropriate Prescribing in the Elderly: a Comparison of the Beers Criteria and the Improved Prescribing in the Elderly Tool (IPET) in Acutely ill Elderly Hospitalised Patients. Journal of Clinical Pharmacological Therapy, 31 (6): 617 26. 217

3. Department of Health, Social Services and Public Safety (2008). Nursing Homes: Minimum standards. http://www.dhsspsni.gov.uk/care_standards_-_nursing_homes.pdf 4. McMurdo, M and Witham,M. (2007) Health and Welfare of Older People in Care Homes. May, 5..334(7600) 913-914. British Medical Journal. 5. National Institute for Health and Clinical Excellence. (2010) Quality Standards for Dementia. http://www.nice.org.uk/aboutnice/qualitystandards/dementia/ Responsibility for Delivery / Implementation HSCB PHA LCGs HSCTs GPs/ Community Pharmacy/Primary Care Delivery and Implementation Partners Voluntary and Community Sector Independent Sector Northern Ireland Housing Executive Quality Dimensions Person-centred - Supports care in place and focuses on solutions for the individual. Safety - Enhances specialist support to residents in Nursing Homes. Timeliness - The provision of specialist support to residents and nursing home teams as soon as possible after the need is identified. Effectiveness - Improved health and wellbeing of resident. Efficiency - Availability of such support in all nursing homes will reduce need to fund care for older people in the acute sector as well as in the community. 218

Performance Indicator 1. Number of residents seen by specialist staff in nursing homes 2. Unscheduled hospital admissions of Care Home residents Data Source Trust report Patient Administration System / Ambulance Service Report Anticipated Performance Level Establish baseline Performance level set once baseline is established Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) March 2015 (end of Year 1) and ongoing 219

Standard 44: Person-centred Palliative and End of Life Care All older people identified to have End of Life Care needs should have a key worker and access to effective palliative and supportive care services for end of life needs. Rationale Palliative and end of life care is the active, holistic care of patients with advanced progressive illness. It is an integral part of the care delivered by all health and social care professionals, and by families and carers, to those living with, and dying from any advanced, progressive and incurable conditions. Palliative and End of Life Care focuses on the person rather than the disease and aims to ensure quality of life from diagnosis onwards. Older people should have the opportunity to make decisions in respect of their end of life options. These should include access to support provided by a multi-disciplinary team who are responsive to their individual needs and wishes so that they can be cared for and die in their place of choice. This should be contained in the written record of an Advanced Care Plan. Effective palliative and End of Life Care should be delivered by competent staff providing patient-centred care focused on the needs of patients and families. It can respond to a range of conditions, is proactive in pre-planning and is supportive of people dying at home or close to home if that is their choice. Evaluations and audits have shown the following outcomes from the Gold Standards Framework: more openness and confidence of staff; improved practice systems of care; improved outcomes for patients and carers. 220

Evidence 1. Department of Health, Social Services and Public Safety (2009) Palliative and End of life Care Strategy for Northern Ireland. http://www.dhsspsni.gov.uk/8555_palliative_final.pdf 2. Ellershaw, J.E., Wilkinson, S. (2003). Care of the Dying: a Pathway to Excellence. Oxford: University Press. 3. Foote, C. and Stanners, S. (2002) Integrating Care for Older People - New Care for Old - A Systems Approach. London: Jessica Kingsley. 4. Harrison, S. et al. (2008) Identifying Alternatives to Hospital for People at the End of Life. The Balance of Care Group /National Audit Office. http://www.balanceofcare.co.uk/downloads/balance%20of%20care%20- %20NAO%20-%20End%20of%20Life%20Care%20Report%20v1.1.3.pdf 5. Khan, S.A., Tarver, K., Fisher, S., Butler. C. (2007). Inappropriate Admissions of Palliative Care Patients to Hospital: a Prospective Audit. London: Pilgrims Hospices. 6. National Health Service Gold Standards Framework Programme (2006) Prognostic Indicator Guidance (version 2.25). http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/eolc-prognostic-indicatorguide.pdf 7. Pleschberger, S.(2007) Dignity and the Challenge of Dying in Nursing Homes: The Residents' View. Age and Ageing 2007; 36: 197-202. http://www.ncbi.nlm.nih.gov/pubmed/17208924 Responsibility for Delivery/ Implementation HSCB PHA LCGs HSCTs GPs/ Primary Care/Community Pharmacy Delivery and Implementation Partners Voluntary and Community Sector Independent Sector 221

Quality Dimensions Person-centred - Focuses on the needs of patients, families and carers. Safety - Evidence based practice safer patient care. Timeliness - Effective palliative care systems will facilitate improvements in care and support for patients, families and carers. Effectiveness - Palliative care is evidenced based. Efficiency - Reduces inappropriate use of acute hospital beds. Performance Indicator 1. Number of patients and family members or friends who participate in person-centred training to promote optimal health and wellbeing through information, counselling and support for people with end of life care needs 2. Patient identified to have palliative and end of life care needs allocated a key worker Data Source Anticipated Performance Level Trust Report and service user/carer feedback Trust report Establish baseline Performance level set once baseline is established Establish baseline Performance level set once baseline is established Date to be achieved by March 2015 (end of Year 1) and ongoing March 2015 (end of Year 1) 222

3. Number of older people dying in hospital having been admitted from nursing homes. 4 All patients identified to have palliative and end of life needs should have the opportunity for holistic assessment and advance care planning Patient Administration System Trust Report NISAT Establish baseline Performance level set once baseline is established Performance level set once baseline is established March 2015 (end of Year 1) and ongoing March 2015 (end of Year 1) 223

Standard 45: Palliative and End of Life Care (Generic) All people with advanced progressive incurable conditions, in conjunction with their carers, should be supported to have their end of life care needs expressed and to die in their preferred place of care. Rationale Most people would prefer to die at home (including residential and nursing home where this is the person s usual home) where this is possible. In order to support this, identification of the possible last year/months/weeks of life should take place. Evidence shows that when end of life care needs are identified there is improved quality of life and even prolonged life, compared to when this stage of illness is not identified, particular in non-cancer conditions. Advanced care planning allows more informed choice of care and enables people to be more supported to die in their preferred place of care. *Palliative care is the active holistic care of patients with advanced, progressive illness. Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with other treatments. (WHO, 2002) *End of life care refers to the possible last year of life. It helps all those with advanced, progressive, incurable conditions to live as well as possible until they die. It enables the supportive and palliative care needs of both the patient and the family to be identified and met throughout the last phase of life and into bereavement. At this stage however it is often still appropriate to provide acute treatment in conjunction with palliative care, particularly in long term conditions. It includes physical care, management of pain and other symptoms and provision of psychological, social, spiritual and practical support. (National Council for Palliative Care, Focus on Commissioning, Feb 2007). 224

Evidence 1. Living matters, Dying Matters. A Palliative and End of Life Care Strategy for Adults in Northern Ireland, March 2010. http://www.dhsspsni.gov.uk/8555_palliative_final.pdf 2. National Institute for Health and Clinical Excellence (NICE) Improving Supportive and Palliative Care for Adults with Cancer (2004) http://www.nice.org.uk/guidance/csgsp 3. Supportive and Palliative Care for Advanced Heart Failure, Coronary Heart Disease Collaborative, NHS Modernisation Agency (2004) http://www.library.nhs.uk/cardiovascular/viewresource.aspx?resid=78319 4. National Institute for Health and Clinical Excellence (NICE) Chronic Heart Failure; Management of Chronic Heart Failure in Adults in Primary and Secondary Care (2003) http://www.nice.org.uk/guidance/cg5 5. National Institute for Health and Clinical Excellence (NICE) Chronic Obstructive Pulmonary Disease; Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care (2010) http://www.nice.org.uk/guidance/cg12 6. National Institute for Health and Clinical Excellence (NICE) Chronic Obstructive Pulmonary Disease; Quality Standards (2011) http://guidance.nice.org.uk/qualitystandards/qualitystandards.jsp 7. Regional Cancer Framework: A Cancer Control Programme for Northern Ireland DHSSPSNI (2006) http://www.dhsspsni.gov.uk/eeu_cancer_control_programme_eqia.pdf 8. National Institute for Health and Clinical Excellence (NICE) Cancer Service Guidance (CSGSP): Improving supportive and palliative care for patients with cancer, March 2004 http://www.nice.org.uk/guidance/csgsp 9. Definitions of levels of palliative care, National Council for Palliative Care http://www.ncpc.org.uk/site/professionals/explained 10. Gold Standards Prognostic Framework Programme, NHS End of Life Care programme (2006) Prognostic Indicator Paper vs 2.25 www.goldstandardsframework.nhs.uk 225

11.Ellershaw, J.E & Wilkinson, S, (2003), Care of the Dying: a Pathway to Excellence, Oxford University Press 12. Foote, C & Stanners, S, (2002), Integrating Care for Older People New Care for Old A Systems Approach, London, Jessica Kingsley 13. Khan, SA; Tarver, K; Fisher S; Butler C (2007), Inappropriate Admissions of Palliative Care Patients to Hospital: A Prospective Audit, London, Pilgrims Hospices 14. Harrison, S et al, (2008), Identifying Alternatives to Hospital for People at the End of Life, The Balance of Care Group / National Audit Office www.balanceofcare.co.uk 15. Pleschberger, S, (2007), Dignity and the Challenge of Dying in Nursing Homes: The Residents View http://ageing.oxfordjournals.org/content/36/2/197.short Responsibility for delivery / implementation HSC Board Public Health Agency (PHA) HSC Trusts Primary Care Delivery and Implementation Partners NICaN Supportive and Palliative Care Network Primary care team, inclusive of social care Voluntary palliative care organisations Private nursing home and care providers 226

Quality Dimension Person-centred - Earlier identification of palliative care needs and advance care planning will help improve quality of life and support a good death. Effectiveness - Inappropriate admissions to hospital at the very end of life will be avoided. Equity - People with non cancer conditions will have access to care and services traditionally available mainly to those with cancer conditions only. Performance Indicator 1. Percentage of the population that is enabled to die in their preferred place of care. Data source NISRA survey for baseline of the population s preference Registrar General and PAS information for actual place of death Anticipated Performance Level Establish baseline Performance levels to be determined when baseline established Date to be achieved by March 2014 March 2015 2. Percentage of population with a understanding of advance care planning NISRA survey for baseline levels Establish baseline Performance levels to be determined when baseline established March 2014 March 2015 227

Standard 46: Improved Dementia and Mental Health Services Older people with mental health conditions or dementia should, from an early stage, access services and environments that provide skilled assessment, treatment and care enabling them to maintain as much independence as possible. Rationale The most common mental health problems in older people are depression and dementia. There is a widespread belief that these are a natural part of the ageing process. Only 20% of people over 85, and 5% over 65, have dementia and 10-15% of those over 65 have depression. Depression affects proportionately more older people than any other demographic group because older people face more events and situations that may trigger depression, physical illness, debilitating physical conditions, bereavement, poverty or isolation. Depression can lead to suicide. Less frequent mental health problems that affect older people are anxiety and late-onset schizophrenia. These conditions may have different causes and symptoms for older people than for other age groups - for example, chronic illness and pain, loneliness or decline in mobility. Older people should be able to access the same range and quality of mental health services which are available to the wider adult population. Evidence on early intervention in mental illness, or dementia in the community or hospital settings suggests better outcomes for older people and efficiency in use of resources. People who experience memory problems should have access to specialist assessment, diagnosis and treatment where appropriate. This includes access to general health services to ensure that any treatable conditions are addressed. They should have access to high quality information and re-ablement support to help them remain as independent as possible within their own family and community networks. It has been estimated that if older people, who are beginning to experience cognitive decline, are given appropriate support, it can delay the progression of dementia by five years. 228

There is a growing evidence to support the development of reablement approaches in supported living options and in the use of assistive technology. These options should be exhausted before entry into care homes is considered. The availability of highly skilled therapeutic services to those who experience severe behavioural symptoms can alleviate the symptoms and enable people to live in community settings. There is evidence that effective multidisciplinary liaison services for older people while in hospital improve outcomes for individuals and reduces unnecessary delays in their discharge from hospital. Community services should be available as appropriate alternatives to inpatient care to avoid unnecessary admission for older people with mental health problems. Services such as crisis intervention, home treatment as well as inpatient services should be tailored to the specific needs of older people. The skills, knowledge and attitude of all staff need to be appropriate to provide effective approaches and interventions thus highlighting the importance of workforce development in this area. Evidence 1. Bamford, D. (2007) Review of Mental Health and Learning Disability: Living Fuller Lives. Belfast: Department of Health, Social Services and Public Safety. http://www.dhsspsni.gov.uk/bamford_consultation_document.pdf 2. Department of Health, Social Services and Public Safety (2009) Improving Dementia Services in Northern Ireland: A Regional Strategy (November 2011). http://www.dhsspsni.gov.uk/improving-dementia-services-in-northern-irelandconsultation-may-2010.pdf 3. NHS/SDO Funded Programme, Liaison Psychiatry Services for Older People Project April 2006-June 2008 University of Leeds. http://www.leeds.ac.uk/lpop/current%20docs/sdo%20delegate%20lit%20draft%203.pdf 4. Living Well At Home Inquiry: All Party Parliamentary Group on Housing and Care for Older People. London: Counsel and Care. http://www.counselandcare.org.uk/pdf/living-well-at-home 229

5. National Institute for Health and Clinical Excellence and Social Care Institute for Excellence (2007) Guidelines on Supporting People with Dementia and their Carers in Health and Social Care. http://www.nice.org.uk/nicemedia/pdf/cg42dementiafinal.pdf 6. Social Care Institute for Excellence (2006) Assessing the Mental Health Needs of Older People. Practice Guide 2. Porteus, J. (2011). http://www.scie.org.uk/publications/guides/guide03/files/guide03.pdf 7. Who Cares Wins Report of a Working Party for the Faculty of Old Age Psychiatry, Royal College of Psychiatrists January 2005. http://www.rcpsych.ac.uk/pdf/whocareswins.pdf 8. In-patient Care for Older People within Mental Health Services Faculty Report FR/OA/1 April 2011. Responsibility for Delivery/ Delivery and Implementation Implementation Partners HSCB Voluntary and Community Sector PHA Independent Sector LCGs Northern Ireland Housing HSCTs Executive/ Housing Associations GPs/ Primary Care/Community Pharmacy Quality Dimensions Person-centred - Individuals will receive a bespoke support package appropriate to their needs/wishes. Safety - Mental health problems or dementia, if identified, assessed and supported appropriately, can minimise risk and maximise potential for independence. Timeliness - Early identification and support will offer best potential for recovery/support and quality of life. Effectiveness - Evidence suggests appropriate access to skilled interventions will provide recovery and quality of life. Efficiency - Postponement of more intensive services will reduce costs. 230

Performance Indicator 1. Trusts should have detailed information on all services for people with mental health conditions including dementia, highlighting linkages, gaps and usage 2. Trusts should provide detailed information on all services for older people with dementia and mental health conditions. This should show the full continuum of services in community and hospital and include activity and outcomes. This needs to show evidence of shifts towards prevention approaches. Data Source Anticipated Performance Level Date to be achieved by Trust Report 100% March 2015 (end of Year 1) and ongoing Trust Report 100% March 2015 (end of Year 1) and ongoing 231

ANNEX A List of Service Frameworks: Service Framework for Cardiovascular Health and Wellbeing Service Framework for Respiratory Health and Wellbeing Service Framework for Cancer Prevention, Treatment and Care Service Framework for Mental Health and Wellbeing Service Framework for Learning Disability Available at: http://www.dhsspsni.gov.uk Service Frameworks in development: Service Framework for Children and Young People s Health and Wellbeing 232

Glossary of Terms: ANNEX B Abuse Advance Care Plans Advocacy Appropriate Medication Assessment Audit Care Home Care Plan Is a violation of an individual s human and civil rights by another person or persons. It includes physical, psychological, sexual, financial, discriminatory abuse, institutional abuse and neglect. Incidents of abuse may be multiple, either to one person in a continuing relationship or service context or to more than one person at a time. Advance care planning is to develop better communication and recording of decisions thereby leading to provision of care based on the needs and preferences of the person and his/her carers. Supports and/or speaks up for people who feel they are not being heard and supporting them to express their own views and ultimately, where possible, to make their own decisions and take control over their own lives. The right person receives the right medicine in the right dose in the right formulation at the right time. A person-centred process whereby the needs of an individual are identified and their impact on daily living and quality of life is evaluated, undertaken with the individual, his/her carer and relevant professionals. Systematic review of the procedures that examines how associated resources are used and investigates the effect that care has on the outcome and quality of life for the patient. Provides residential care and accommodation or nursing care and accommodation for persons who need this care and support by reason of, old age and infirmity, disability, past or present dependence on alcohol or drugs; or past or present mental disorder. The outcome of an assessment. A description of what an individual needs and how these needs will be met. 233

Care Planning Carer Case Records Case Finding A process based on an assessment of an individual s need that involves ascertaining the level and type of support required to meet those needs, and the objectives and potential outcomes that can be achieved. A person who, without payment, provides help and support to a family member or friend who may not be able to manage at home without this help because of frailty, illness or disability. It excludes paid care workers and volunteers from voluntary organisations. Records or documents containing information which has been created or maintained as evidence of patient /client care given, and care/ treatment planned. Includes proactively publicising information about health and social care services and how to access them in an accessible, informative and user friendly manner which will assist both those who are likely to require support and/or services, and referring agencies (including General Practitioners) in making appropriate referrals. Commissioning Is the process of meeting needs at the strategic level for whole groups of service users and/or whole populations and of developing policy directions, service models and the market to meet those needs in the most appropriate and cost effective way. Comprehensive Geriatric Assessments A process that determines an older person s medical, psychological, social, functional and environmental resources and problems and creates an overall plan for treatment and follow-up. It encompasses linkage of medical and social care around medical diagnoses and decision-making under the leadership of a Doctor trained in geriatric medicine. 234

Direct Payments Domiciliary/Ho me Care Evidence-based (care/practices) Money paid by HSC Trusts that allows individuals to arrange for themselves the social care services required to meet their needs as assessed. The range of services put in place to support a person in their own home. An approach to decision-making where staff use the best evidence available, in consultation with service users, their representatives and relevant health care professionals to decide upon the option which suits each patient best. Financial Abuse Includes illegal or improper use of a person's property, money, pension book, bank account or other valuables, as well as stealing money or property. Gold Standards Framework Independent Sector Providers Intermediate Care A systematic, evidence based approach to identifying patients nearing the end of life and optimising the care provided to them in Primary Care settings. Is the umbrella term for all non-statutory organisations delivering public care including the voluntary, community and private sectors. A short period (normally no longer than six weeks) of intensive rehabilitation and treatment to enable people to return home following hospitalisation; or to prevent admission to a long term residential care or nursing home; or intensive care at home to prevent unnecessary hospital admission. Long Term Condition Medicines Reconciliation Illnesses, which last longer than a year, usually degenerative causing limitations to one s physical, mental and/or social wellbeing. Long Term Conditions include diabetes, COPD, asthma, arthritis, epilepsy and mental health problems. Multiple long-term conditions make care particularly complex. The process of identifying the most accurate list of all medicines a person is taking, including name, dose, frequency and routes. 235

Medicines Review Multi-factorial, Evidence-based Falls Assessment Neglect Northern Ireland Single Assessment Tool (NISAT) Nursing Home Orthogeriatric Support Palliative Care Key Worker Checking the impact of medicines to maximise a person s health and it gives the person an opportunity to raise questions and highlight problems about their medicines. A process that examines medical, psychological, social and environmental factors contributing to risk of falls. Factors assessed are based on research evidence. It is abusive to deprive a person of food, clothes, warmth and hygiene needs. Older people also have the right to have the healthcare treatment or medication they need. They also should not be isolated from social interaction or left unattended for periods of time if that puts them at risk or causes them distress or anxiety. Has been designed to capture the information required for holistic, person-centred assessment of the health and social care needs of the older person. It reduces duplication and promotes multidisciplinary working. Its focus is on the person s abilities and strengths rather than their disabilities. It standardises and streamlines assessment and care planning processes, thereby simplifying access to community care services. Means, with specified exceptions, for example, a hospital, any premises used, or intended to be used, for the reception of, and the provision of nursing for, persons suffering from any illness or infirmity. Input from a Doctor with specialist knowledge and skills in orthopaedics and geriatric medicine. An identified individual with responsibility for planning and coordinating patient care across interfaces, promoting continuity of care and ensuring that the patient and health and social care staff know how to access information and advice. The key worker can be the individual s General Practitioner, Community Nurse, Specialist Nurse, Social Worker, AHP or any person identified by the multidisciplinary team. 236

Palliative Care Team Peer Educator Multi-disciplinary care team, including nursing medical and allied health professionals as well as non-clinical members such as social work staff, chaplains, counsellors and volunteers. This will enable patients to achieve their optimum quality of life through holistic support and rehabilitation. They will manage physical pain, unresolved symptoms, complex psychosocial, end of life issues and bereavement issues with individuals and their families. Person who is trained to work with contemporaries or a locality to keep people safe from harm, abuse or exploitation rather than experts doing it to them. Peer Education Peer Education is an approach to health promotion, in which community members are supported to promote health-enhancing change among their peers. The concept is based on the assumption is that lay people are in the best position to encourage healthy behaviour to each other. Person-centred Assessment Protection Plan Re-ablement Rehabilitation Respite Care Safeguarding An assessment, which places the individual at the centre of the process and which responds flexibly and sensitively to his/her needs. The actions that are required to keep the older person safe from further abuse or harm. The Protection Plan will also set out timescales for action, note who is responsible for each action and specify when the Protection Plan will be reviewed. Timely and focussed intensive support to maximise long term independence and minimise the need for ongoing support by enabling the older person to learn or re-learn skills important to them for daily living. This is the process of helping a person achieve the highest level of function, independence and quality of life possible. Temporary residential care, nursing home or social accommodation provided to an ill or disabled person to allow a carer a break from caring. Respite care may also be delivered in the service user s own home. The term short breaks has also been used. All work to keep adults at risk safe from abuse or significant harm. 237

Screening Screening Tool Service User Significant Harm Symptom Control Vulnerable Person Examining a referral to determine the most appropriate response and the further level of assessment that is required. An aid to assess patients health status e.g. nutritional screening tool is an aid to assess the nutritional status of patients. A person who is receiving or is eligible to receive health and social care services. They may be individuals staying in their own homes, living in residential care or nursing homes, or being cared for in hospital. Not only abuse (including sexual abuse and forms of ill-treatment which are not physical) but also the impairment of or an avoidable deterioration in physical health or the impairment of physical, intellectual, emotional, social or behavioural development. The management of any/all symptoms a patient may experience in order to promote comfort and enhance the quality of life. It is much more than pain relief, although this is an important feature of symptom control. Someone who is, or may be, in need of community care services, or is resident in a continuing care facility by reason of mental or other disability, age or illness, or who is, or may be, unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation. 238

Abbreviations: ANNEX C AHP BHSCT CAS CAM CSR DHSSPS GAIN GP HSC IHCP LASP LCGs NHS NHSCT NI NIASP NIAS NISAT NICE OFMDFM PCC PHA PPI QOF RQIA SAAT SCIE SEHSCT SELCG SHSCT UK US WHSCT Allied Health Professional Belfast Health and Social Care Trust Confusional Assessment Scale Shortened Version of CAS Comprehensive Spending Review Department of Health, Social Services and Public Safety Guidelines and Audit Implementation Network General Practitioner Health and Social Care Independent Health Care Provider Local Adult Safeguarding Partnership Local Commissioning Groups National Health Service Northern Health and Social Care Trust Northern Ireland Northern Ireland Adult Safeguarding Partnership Northern Ireland Ambulance Service Northern Ireland Single Assessment Tool National Institute for Clinical Excellence Office of First Minister and Deputy First Minister Patient and Client Council Public Health Agency Personal and Public Involvement Quality Outcomes Framework Regulation and Quality Improvement Authority Self Assessment Audit Tool Social Care Institute for Excellence South Eastern Health and Social Care Trust South Eastern Local Commissioning Group Southern Health and Social Care Trust United Kingdom United States Western Health and Social Care Trust 239

Project Team: ANNEX D Name Job Title Organisation Dr Cathy Jack Co Chair of Project Team and Deputy Medical Director Belfast Health and Social Care Trust (BHSCT) Kevin Keenan Co Chair of Project Team and Assistant Director of Health and Social Care Board (HSCB) Older People and Adults Chris Totten Head of Health and Social Wellbeing Improvement, Public Health Agency (PHA) South- Eastern Area Seamus McErlean Social Care Commissioning Lead, Older People and Health and Social Care Board (HSCB) Adults Helen Ferguson Director Carers (NI) Marie B Heaney Joyce McKee Dr Barbara English Dr Nigel Campbell Dr Susan Patterson Joe Brogan Majella Townley Shirley Tang Michelle Tennyson Service Manager, Older People s Services Regional Adult Safeguarding Officer Consultant Psychogeriatrician LCG Chair Person and General Practitioner Medicines Management Adviser Assistant Director, Integrated Care, Pharmacy and Medicines Management Information Services Manager Programme Manager, Performance Management and Service Improvement (PMSI) Assistant Director, Allied Health Professions and Public and Personal Involvement Belfast Health and Social Care Trust (BHSCT) Health and Social Care Board (HSCB) Belfast Health and Social Care Trust (BHSCT) South Eastern Local Commissioning Group (SELCG) Health and Social Care Board (HSCB) Health and Social Care Board (HSCB) Health and Social Care Board (HSCB) Health and Social Care Board (HSCB) Public Health Agency (PHA) 240

Name Job Title Organisation Pat Newe Social Services Officer Department of Health, Social Services and Public Safety (DHSSPS) Clifford Coulter Head Accountant Health and Social Care Pat Cullen Dr Michael Harriott Brian Taggart George Russell Stephanie Ward Colin Wallace Michael Swann Commissioning Assistant Director, Nursing and Safety, Quality and Patient/Client Experience Chair Person of the Service User Reference Group Deputy Principal, Elderly Care Deputy Principal, Standards Guidelines, Quality Branch Staff Officer, Standards Guidelines, Quality Branch Staff Officer, Safety and Quality Branch Principal, Elderly and Community Care Board (HSCB) Public Health Agency (PHA) Patient and Client Council (PCC) Department of Health, Social Services and Public Safety (DHSSPS) Department of Health, Social Services and Public Safety (DHSSPS) Department of Health, Social Services and Public Safety (DHSSPS) Department of Health, Social Services and Public Safety (DHSSPS) Department of Health, Social Services and Public Safety (DHSSPS) Audrey Lockhart Project Manager Health and Social Care Board (HSCB) 241

Older People s Reference Group: ANNEX E Dr Michael Harriott Anne Gamble June Mallon Anne Mallon Anne Watson Caroline Kelly Dessie Cowan Dr Paul Hudson Elizabeth Zammitt Eugene Magill Gerry Pots Irene Harper Karen McCartney May Morrison Patricia Donald Roberta Johnson Chairperson Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer Service User/Carer 242

Membership of Sub Groups: ANNEX F Sub Group Lead Person-centred Care: Seamus McErlean, Social Care Commissioning Lead, Older People and Adults, HSCB Name Job Title Organisation Gerry Maguire Social Care HSCB Commissioning Lead Bernardine McCrory Acting Director Alzheimer s Society Janet Montgomery Director Hutchinson s Care Independent Health Care Providers (IHCP) Homes Judith Cross Strategic Policy Adviser Age (NI) Dr Michael Power Health and Care Consultant Physician in Geriatric Medicine South Eastern Health and Social Care Trust (SEHSCT) University of Ulster Prof Brendan McCormack Professor of Nursing Research Faith Gibson Emeritus Professor of University of Ulster Social Work Claire McGartland Lead Allied Health PHA Professional Consultant Rosemary McClure Retired Social Worker Service User/Carer 243

Sub Group Lead Health and Wellbeing Improvement: Chris Totten, Head of Health and Social Wellbeing Improvement, South-Eastern Area, PHA Name Job Title Organisation Colette Brolly Health and Social Wellbeing PHA Improvement Manager Sarah Browne Assistant Director, Older SEHSCT People s Services Angela Denvir Health Improvement and Community Development Lead Northern Health and Social Care Trust (NHSCT) 244

Sub Group Lead Safeguarding: Joyce McKee, Regional Adult Safeguarding Officer, HSCB Name Job Title Organisation Aidan Gordon Assistant Director, Adult WHSCT Safeguarding Anne Hillis Senior Commissioning Manager, HSCB Belfast LCG Deirdre Hegarty Trust Adult Safeguarding BHSCT Specialist Jacqui Corscadden Head of Services Age (NI) Rosemary Magill Area Manager Women s Aid Kim Campbell Primary Care Manager SEHSCT Linda Johnston Operation s Manager, Social SEHSCT Work Lead Eilis McDaniel Acting Head of Child Care Policy DHSSPS Directorate Hugh Mills Chief Executive IHCP Patricia Trainor Trust Lead Professional for SHSCT Safeguarding Dr Paul Darragh Consultant in Public Health PHA Medicine Randal McHugh Principal Practitioner NHSCT Thelma Abernethy Area Manager Alzheimer s Society Anne McKee Volunteer Women s Aid Laurence Wright Development Manager Engage with Age Sadie Anderson Volunteer Engage with Age Beverly McCallum Committee Member of Belfast Engage with Age East Seniors Forum Alison Conroy Inspector Criminal Justice Police Service NI Dr Ian Steele Consultant Physician in Geriatric Medicine BHSCT 245

Sub Group Lead Carers: Helen Ferguson, Director, Carers Northern Ireland Name Job Title Organisation Margaret McDonald Carer Coordinator BHSCT Joan Scott Carers Development SEHSCT Officer Paul McCormack Development Manager Princess Royal Trust for Carers Caryl Williamson Senior Advocate Age (NI) Leandre Monroe Carer Member of BHSCT Carers Reference Group Sam Bell Carer Member of NHSCT Carers Reference Group Dr Timothy Consultant Physician BHSCT Beringer in Geriatric Medicine Alan Corry-Finn Executive Director of WHSCT Nursing and Director of Primary Care and Older Peoples Services Joanne McConville NISAT Project Officer HSCB 246

Sub Group Lead Conditions more common in Older People: Dr Barbara English, Consultant, Psychiatry of Old Age. BHSCT Name Job Title Organisation Dr Lynne Armstrong Consultant Physician in BHSCT Geriatric Medicine Dr Dominic Hart Consultant Physician in BHSCT Geriatric Medicine Dr Maura Young Consultant Psychiatry of NHSCT Old Age Dr April Heaney Consultant Physician in SEHSCT Geriatric Medicine Dr Bronagh McGleenon Consultant Physician in SHSCT Geriatric Medicine Dr Gary Heyburn Consultant BHSCT Orthogeriatrician Dr Stephen Compton Retired Consultant Carer Psychogeriatrician Jane Greene Nurse Consultant SHSCT Gail McMillan Clinical Team Lead BHSCT Physiotherapist Linda Robinson Service Director Age (NI) Nicola Peden Specialist stroke Dietician SEHSCT 247

Sub Group Lead Medicines Management: Dr Susan Patterson, Pharmacy & Medicines Management Adviser, HSCB Name Job Title Organisation Dr Nigel Campbell LCG Chair Person and General SELCG Practitioner Clare Conroy Clinical Pharmacist, Intermediate BHSCT Care Aideen O Kane Clinical Pharmacy Co-ordinator BHSCT Briegeen Girvin Medicines Governance HSCB Pharmacist/Primary Care Deirdre Quinn Pharmaceutical Services Lead HSCB Dr Norman Morrow Chief Pharmaceutical Officer DHSSPS 248

Sub Group Lead Transitions of Care: Marie B Heaney, Service Manager Older Peoples Services, BHSCT Name Job Title Organisation Patrick Graham Assistant Director, Primary NHSCT Care and Community Care Older People s Services, Fiona McAnespie Senior Manager, Older SEHCT People s Services, Linda Robinson Director of Services, Age Concern Brendan Duffy Senior Manager, Older WHSCT People s Services Dr Ken Fullerton Consultant Physician in BHSCT Geriatric Medicine Ricky Stewart Care Manager BHSCT Jillian Martin Manager, Older People s BHSCT Services Brendan Whittle Assistant Director, Older SHSCT Peoples Services Dr Edmund Hodkinson Consultant Physician in WHSCT Geriatric Medicine Barbara Gregg NISAT Project Officer BHSCT 249

250 ANNEX G Comments and Recommendations made by the Older People s Reference Group on the Standards of Service developed for the Service Framework for Older People The Reference Group emerged from a partnership between the Department of Health, Social Services and Public Safety, the Health and Social Care Board and the Patient and Client Council. Members were recruited through a process designed and delivered by the Patient and Client Council, Carers (NI) and Age (NI). The Reference Group comprised 17 older people from diverse backgrounds, with recent and current experience of using the services under consideration as patients, clients and carers. Members were active in communities of older people across Northern Ireland. As such, they were able to reflect genuine patient and carer views on the developing standards. The Reference Group was a pioneering initiative. The Group was given status within the project structure and the Chairman had a place on the Project Board. The Group was able to ask Sub Group leads to attend its meetings and to question them closely on the standards that they were developing. It fed back its comments through the Chairman direct to the Project Board in a series of reports. As a result, the people for whom the Framework is designed had a significant and sustained input into its development throughout the whole process of drafting. This is a far cry from the widespread consultation practice of the past where people complained often that they were consulted only after the key decisions had been made. The Reference Group members gave freely and enthusiastically of their time and experience and in return received honest and open engagement from the Project Board and Sub Group Leads. Fostering a collaborative partnership approach is the most effective way to raise standards in the Health and Social Care service. Only then can we expect to deliver effective services in a way that ensures dignity and respect for older people within our society. It is important to note that this summary and the report were produced to inform the draft document in advance of it, in other

words. I am pleased to note that so much of what the Group had to say is reflected in the final document. On behalf of the Older People s Reference Group, I am pleased to present this summary of the final report of the Group s comments and recommendations. A copy of the full report is available from: http://www.patientclientcouncil.hscni.net. Dr Michael Harriott (Chair) Service Framework for Older People 251

ANNEX H SUMMARY OF REPORT AND RECOMMENDATIONS ON THE SERVICE FRAMEWORK FOR OLDER PEOPLE 1. Introduction 1.1 The Service Framework for Older People s Reference Group was established on 21 st June 2010. It was a group of older people with experience as users and carers of Health and Social Care services in Northern Ireland. 1.2 Its remit was to provide comments and recommendations on a draft Service Framework document commissioned by the Department of Health, Social Services and Public Safety on the health and wellbeing of older people. 1.3 While senior officials were responsible for the writing of the framework, a reference group of 17 older people and carers from across Northern Ireland were recruited by the Patient and Client Council, Carers (NI) and Age (NI) to review what was written, to ask questions and to make suggestions. 1.4 During 2010, the Reference Group conducted a number of workshops covering the six headings under which the Project Board had decided the Sub Groups should develop standards (1): Support for Carers and Identifying Carers Needs; Protection of Vulnerable Older People; Care Management, Management of Transitions and Promoting Independence; Person-centred Care; Promoting Health and Social Wellbeing in Older People; Conditions More Common in Older People. 1.5 The workshops were a unique opportunity to inform policy makers, service commissioners and providers of health and social care services about the experiences and anxieties of older people and to highlight what was missing within the draft framework. (1) Following consideration of the Reference Group Report a decision was made to produce separate standards on Medicines Management by a seventh workstream. 252

2. Overview of Report and Recommendations 2.1 The recommendations made by the Group validate the six themes within the draft framework and underscore the capacity of collaborative partnership between patients, clients and carers on the one hand and service commissioners and providers on the other, to make real, sustainable change in the health and social care of older people. In other words, the partnership evident in the development of the standards should be evident in their implementation. 2.2. The individual recommendations appear within each sub group heading in the full report of the Reference Group (available at http://www.patientclientcouncil.hscni.net). The following paragraphs summarise the key themes contained within the recommendations and include all the recommendations made within the report for additional standards. 3. Recommendations 3.1 Recommendations by the group fell into three categories: Recommendations to be applied to the Whole Framework; Recommendations to be applied to Individual Standards; Additional Standards. 4. Recommendations to be applied to the Whole Framework 4.1 The language used within the framework should be simplified. Clinical terms should be avoided. Care should be taken in the use of terms. Definitions should be included where necessary. 4.2 The standards set should be achievable. They should avoid being merely aspirations. 4.3 All standards should be capable of being monitored. Performance indicators and outcomes should be measurable. The baseline from which attainment of the standard begins should be included. It should be clear to the public when a standard has been met. 4.4 Duplication of standards under different sub headings should be eliminated. The interdependence of the standards should be made clear. 253

4.5 Financial aspects of the strategy should be made more explicit. Where a service change results in a saving this should be demonstrated. 5. Recommendations to be applied to Individual Standards Presented 5.1 In many cases, the Group felt that standards should be strengthened and they sought assurances that an appropriate emphasis would be given to the standard within the final framework. Each of these recommendations can be found in the full report; however, the Group expressed particular concerns around: The recognition of Carers; Services provided in response to individual need; Standards for the recognition and awareness of abuse; Standards for continence services. 6. Additional Standards 6.1 All of the recommendations made by the Group appear below. These recommendations fall under two main headings: Standards that empower Older People; Standards that encourage Service Change. 6.2 Additional Standards Recommended: 6.2.1 Standards for Carers and Identifying Carers Needs: Standards should improve carer recognition in the first instance and propose practical means for achieving this; Standards should secure greater carer participation in care planning arrangements and offer flexibility to carers, especially in the provision of respite services; There should be a general standard for assessment, which makes the responsibility for assessment clear and the process of assessment understandable and transparent to all involved in it; There should be recognition of the health and wellbeing needs of carers as part of the standards, for example, recognition of the impact of social isolation and stress on carers and initiatives to address these. 254

6.2.2 Protection of Vulnerable Older People: In general, the Group felt that standards needed to be developed to deal with awareness, prevention and identification of abuse before it was formally reported. The Group recognised the arrangements that had been put in place to deal with reported abuse. 6.2.3 Single Point of Entry: The Group felt that social care is overlooked. All older people can make decisions about their care but do not have the right to participate fully in their own assessment. The standards should set out what service they can expect. Their entitlements and their right to participate in decisions about themselves should be enforced through personalised budgets and greater use of Direct Payments. 6.2.4 Care of Patients in Hospitals: Patients notes should be with nurses when the patient arrives at the care home/hospital so that an exact picture of the patient s history is immediately available. Use of a memory stick carried by the patient or carer for this purpose was suggested. 6.2.5 Intermediate Services: The management and allocation of domiciliary care should be hourly based and not task based with a supporting standard on quality of care. 6.2.6 Long Term Living: The Group stated that there is no real medical care in nursing homes. A large proportion of people in nursing homes may need rapid access to specialised care. A standard should be introduced to address this deficit. Most patients in nursing homes want to stay there at the end of their lives. They do not wish to be admitted to hospital in their last days and hours. A standard should be introduced that respects this and allows both GP and Palliative Care teams to act in accordance with patient wishes. This should have the effect of saving resources used for inappropriate emergency admissions and reduced stress on families at the end of life. 255

A standard should be introduced on care in the days after death. This standard should include spiritual/cultural assessments to be written in dealing with funeral arrangements, arrangements and consents for post mortems and access to support for families. 6.2.7 Person Centred Care: There is a need for an ethical framework for services, linking general service standards with professional ethical requirements. Members felt that a standard should be written about a shift of power to personalised care/budgets including support that enables people to make their own choices and to be given the information to do so. There should be a standard of agreement with patients that identify how and why decisions were made. This information should be part of patients records. There should be a standard to protect against discrimination against older people. 6.2.8 Falls: Alcohol and drugs should be listed as a reason for an older person falling. 6.2.9 Nutrition: Risk of aspiration pneumonia to be included, under the umbrella term of physical problems. The identification and avoidance of dehydration to be included, within the nutrition standard. 6.2.10 Continence: The continence standard for hospital management is underdeveloped. The emphasis on dignity and respect must include a requirement that patients when bathing will be assisted only by staff of the same sex. 6.2.11 Delirium: Standards should include an element of training for staff that ensures carers and family are briefed about delirium and its effect on the patient. 256

Legislative and Policy Context ANNEX I The following pieces of legislation provide the legislative framework for the provision of health and social care services in Northern Ireland. (i) The Health and Personal Social Services (Northern Ireland) Orders and the Health and Social Care (Reform) Act (Northern Ireland) 2009 The Health and Personal Social Services (NI) Order 1972 as amended by the Health and Personal Social Services (NI) Order 1991; the Health and Personal Social Services (NI) Order 1994; the Health and Personal Social Services (Northern Ireland) Order 1978; and the Health and Social Care (Reform) Act (NI) 2009 (the Reform Act 2009) are central to the provision of health and social care in Northern Ireland. The legislation imposes a number of duties including: a general duty to promote an integrated system of health and social care designed to secure improvement in the physical and mental health and social wellbeing of people in Northern Ireland and in the prevention, diagnosis and treatment of illness; a duty to make arrangements, to such extent as the Department considers necessary, for the prevention of illness and the care and aftercare of a person suffering from illness; a duty to make available advice, guidance and assistance, to such extent as the Department considers necessary, and to make such arrangements and provide or secure the provision of such facilities as it considers suitable and adequate in order for it to discharge its duty to secure improvement in the social wellbeing of people in Northern Ireland; a duty on Health and Social Services Boards (now the Health and Social Care Board ( the Board ) under the Reform Act 2009) to make arrangements in respect of their area for the provision of personal medical services; and a requirement on the Department of Health, Social Services and Public Safety ( the Department ), the Board, Public Health Agency ( PHA ), Health and Social Care Trusts ( Trusts ), and 257

special agencies to promote information about the health and social care for which they are responsible and to seek views from the recipients of health and social care either directly or through representative bodies. (ii) Chronically Sick and Disabled Persons (Northern Ireland) Act 1978 This identifies the need for, and publication of, information about services to promote the social welfare of chronically sick and disabled people; and relates to the provision of services to chronically sick and disabled people. (iii) The Mental Health (Northern Ireland) Order 1986 This outlines the general duty of the Board and Trusts to make arrangements designed to promote mental health, to secure the prevention of mental disorder and to promote the treatment, welfare and care of persons suffering from mental disorder. Mental Health legislation in Northern Ireland has been subject to extensive review and is in the process of change. The proposed Mental Capacity Bill will have a major impact for those older people who are unable to make a decision for themselves. The Bill will provide for substitute decision-making arrangements in respect of health, welfare and finance which are required to be made for anyone lacking the capacity to make the decision for themselves. One of the impairments which may lead to incapacity will be dementia in older people. Importantly as well as providing for the substitute decision-making arrangements, the Bill will provide important safeguards for the person lacking capacity. These could include; assessment of capacity, best interests, reasonable restraint, nominated person, second opinion, advocate, Trust authorisation and Tribunal review. (iv) Disabled Persons (Northern Ireland) Act 1989 This relates to appointment of authorised representatives of disabled persons, the assessment of needs of disabled persons and the duty to take into account the abilities of carers of disabled people. (v) The Disability Discrimination Act 1995 and Disability Discrimination (Northern Ireland) Order 2006 The Disability Discrimination Act 1995 aims to end the discrimination that faces many people with disabilities. This Act 258

has been significantly extended, including by the Disability Discrimination (NI) Order 2006. It now gives people with disabilities rights in the areas of: employment; education; access to goods, facilities and services The legislation requires public bodies to promote equality of opportunity for people with disabilities. It also allows the government to set minimum standards so that people with disabilities can use public transport easily. (vi) The Carers and Direct Payments Act (Northern Ireland) 2002 This allows Trusts to provide personal social services to support carers directly and gave carers the right to an assessment of their own need; empowered Trusts to make Direct Payments to disabled people, older people, people with parental responsibility for a disabled child and to carers to meet their assessed needs. A recent Court judgement has determined that as the 2002 Act stands, people who lack capacity to consent to their receipt cannot receive Direct Payments. The 2002 Act will need to be changed and this could take up to 2 years. (vii) The Health and Personal Social Services (Quality, Improvement and Regulation) (NI) Order 2003 This established a new, independent body, the Regulation and Quality Improvement Authority with responsibility for monitoring the quality of health and social care services and for regulating, for example, residential care and nursing homes and domiciliary care agencies. Separate and specific regulations and published standards apply to such establishments and agencies. The Order also introduced a statutory duty of quality on the Board, Trusts and some special agencies with regard to services which they provide. (viii) The Safeguarding Vulnerable Groups (NI) Order 2007 This provides the framework for a new vetting and barring scheme for people who work with children and vulnerable adults by barring unsuitable individuals as part of a centralised vetting process that all those working closely with children and/or vulnerable adults will need to go through. The arrangements enable vetting and barring processes to operate coherently across the UK. 259

Underpinning all of this, are responsibilities under: (ix) Section 75: Schedule 9 to the Northern Ireland Act 1998 This came into force in January 2000 and placed a statutory obligation on public authorities in carrying out their various functions relating to Northern Ireland, to have due regard to the need to promote equality of opportunity: between persons of different religious belief, political opinion, racial group, age, marital status or sexual orientation; between men and women generally; between persons with a disability and persons without; and between persons with dependants and persons without. In addition, without prejudice to this obligation, Public Authorities are also required to have regard to the desirability of promoting good relations between persons of different religious belief, political opinion, and racial group. (x) The Human Rights Act 1998 Came into effect in 2000 and makes the European Convention on Human Rights part of the law of Northern Ireland. It allows individuals and organisations to go to Court or Tribunal to seek redress if they believe that the rights conferred on them by the European Convention have been violated by a public authority. The Act says that persons carrying out certain functions of a public nature will fall within the definition of a public authority. It should be noted that Section 145 of the Health and Social Care Act 2008 extended the coverage of the Human Rights Act to residents in residential care and nursing homes where their care has been contracted for by Trusts. Key Policy components include: (a) People First: Community Care in Northern Ireland for the 1990s (DHSS) This places emphasis on the requirement, within available resources, to identify and assess individuals needs, taking full account of personal preferences (and those of informal carers), and design packages of care best suited to enabling the consumer to live as normal a life as possible. The Review of Community Care First Report (DHSS 2002) reiterated the need to make proper assessment of need and good case management the cornerstone 260

of high quality care. The central objectives of community care services remain: helping people to remain in their own homes, or in as near a domestic environment as possible, for as long as they wish and it is safe and appropriate to do so; providing practical support to carers to support them in their caring role; and ensuring that residential, nursing and hospital care is reserved for those whose needs cannot be met in any other way. (b) Home Accident Prevention Strategy and Action Plan The Plan was published in November 2004. It highlights falls affecting older people as presenting a significant public health concern and challenge given the growing ageing population in Northern Ireland. DHSSPS is in the process of drafting a new 10 year Home Accident Prevention Strategy which will issue for public consultation during 2012-2013. (c) A Healthier Future A Twenty Year Vision for Health and Well-being in Northern Ireland 2005-2025 (DHSSPS) A Healthier Future is a vision for health and wellbeing in Northern Ireland over the next twenty years and it is intended to give the direction of travel for health and social services. It places a strong emphasis on: promoting public health; engagement with people and communities to improve health and wellbeing; the development of responsive and integrated services which will aim to treat people in communities rather than in hospital; new, more effective and efficient ways of working through multidisciplinary teams; measures to improve the quality of services; and flexible plans, appropriate organisational structures and effective, efficient processes to support implementation of the strategy. (d) Caring for People Beyond Tomorrow A Strategic Framework for the Development of Primary Health and Social Care for Individuals, Families and Communities in Northern Ireland (DHSSPS 2005) 261

This Framework provides: a vision for primary care services over the next 20 years; a framework of principles, values and high-level goals that will make clear the nature of the future primary care system we wish to see developed; and a policy framework that will steer and influence future development and delivery of services. (e) Ageing in an Inclusive Society This was launched in March 2005 and sets out the approach to be taken by Government to promote and support the inclusion of older people in Northern Ireland. Its vision is to ensure that age related policies and practices create an enabling environment, which offers everyone the opportunity to make informed choices so that they may pursue healthy, active and positive ageing. To turn this Vision into reality, six strategic were set out, as follows: to ensure that older people have access to financial and economic resources to lift them out of exclusion and isolation; to deliver integrated services that improve the health and quality of life of older people; to ensure that older people have a decent and secure life in their home and community; to ensure that older people have access to services and facilities that meet their needs and priorities; to promote equality of opportunity for older people and their full participation in civic life, and challenge ageism wherever it is found; to ensure that Government works in a coordinated way interdepartmentally and with social partners to deliver effective services for older people. (f) Caring for Carers: Recognising, Valuing and Supporting the Caring Role (DHSSPS, 2006) The strategy was developed round six areas of concern, which were identified during the original Valuing Carers consultation. These are: the identification of those acting in a caring role; information for carers; support services; the special needs of young carers; training; and employment. 262

Caring for Carers set out a vision of what needs to be done to provide carers with the practical support they want and need to allow them to continue caring, as well as to recognise, value and provide practical support for the important contribution that carers make to our society. (g) Living Fuller Lives The Bamford Review, published in June 2007, made 55 recommendations to enhance services for people with dementia and older people with mental ill-health. These aimed to improve the diagnosis, treatment and care of those who use these services and to give greater support to their carers. It proposed new models of 24-hour support and respite, incorporating responsive and innovative approaches, particularly for those in rural areas. (h) Guidance on Strengthening Personal and Public Involvement in Health and Social Care (DHSSPS, 2007) This guidance is intended to assist Health and Social Care organisations improve the quality and effectiveness of user and public involvement as an integral part of good governance arrangements and to support the development of more patient and user-centred health and social care services. (i) Northern Ireland Single Assessment Tool (NISAT) NISAT was launched in February 2009, the Tool has been designed as the vehicle to capture the information required for holistic, proportionate, person-centred assessment of the health and social care needs of the older person and will result in an assessment that has focussed on the person s abilities and strengths rather than their disabilities. NISAT will standardise and streamline assessment and care planning processes, simplify access to community care services, reduce duplication and promote multi-disciplinary working. NISAT, includes a Carer s Support and Needs Assessment component, and is now being implemented in the Older People s Programme of Care across all 5 HSC Trusts. NISAT also contains triggers which alert staff to potential safeguarding/protection issues. (j) Living Matters Dying Matters A Palliative and End of Life Care Strategy for Adults in Northern Ireland The vision of this 5-year Strategy, published in March 2010, is that any person with an advanced non-curative condition lives well and 263

dies well irrespective of their condition or care setting. To this end, the Strategy promotes a holistic approach to care that enables people to retain control, dignity and crucially, choice in how and where their care is delivered to the end of their life. The Palliative and End of Life Care Strategy provides a strategic framework for Health and Social Care commissioners and providers, as well as voluntary and non-statutory organisations as they seek to design and deliver high quality, equitable and person-centred palliative and end of life care services for patients, their families and carers. The 25 recommendations made in the Strategy have been built into an action plan to enable the planning and delivery of high quality palliative and end of life care. (k) An Age Old Problem A review of the care received by elderly patients undergoing surgery (The National Confidential Enquiry into Patient Outcome and Death (NCEPOD), November 2010) This report looked at the care of people over 80 who were admitted for surgery and died with 30 days of their operation. A sample of 365 hospitals across England, Wales and Northern Ireland participated in the survey. The report made a number of recommendations aimed to improving the care of elderly patients undergoing surgery. These included, the need for multi-disciplinary risk assessments, reducing unnecessary drug treatment, nutritional support and pain management. HSC Trusts in Northern Ireland were asked to note the recommendations in the report and to develop action plan to address these. (l) Quality 2020 A 10-year quality strategy for health and social care in Northern Ireland (DHSSPS, 2011) The purpose of the Strategy is to establish a framework that will protect and improve quality within health and social care over the next 10 years under three main headings: safety; effectiveness; and patient and client focus (m) Improving Dementia Services in Northern Ireland A Regional Strategy (DHSSPS, 2011) This sets the direction of travel for improving dementia services. Key messages in the strategy relate to: prevention; Raising awareness and addressing stigma associated with the condition; access to early diagnosis; a staged approach to care and support as the condition progresses, with the aim of maintaining daily living and independence as far as possible; improving staff awareness 264

and skills to respond appropriately to people s needs; and redesign of services to provide care and support in people s own homes and avoid admission to hospital or care home. (n) The Commissioner for Older People The Commissioner, appointed in November 2011, will have a wide range of promotional, advisory, education and general investigatory functions, duties and powers designed to safeguard and promote older peoples interests, generally and individually. (O) Living with Long Term Conditions A Policy Framework (DHSSPS, 2012) As people live longer they are more likely to develop one or more long term conditions and consequently their need for health and social care interventions will increase significantly. The overall aim of the policy framework is to help the Board, Trusts, the Public Health Agency, the voluntary and community sectors and independent care providers plan and develop more effective services to support people with long term conditions and their carers. The policy framework, which was published in April 2012, outlines a general approach to developing services that will be applicable to adults with a wide range of long term conditions. It is neither disease nor condition specific and is applicable across all care sectors. The document will provide a framework within which commissioners and providers can improve services, share and extend good practice and develop systems and practices that deliver best outcomes for patients. While primarily the policy framework has been developed to be a strategic driver in the reform and modernisation of services, it is also intended to be a useful source of reference for people who live with long term conditions, setting out the services they and their carers should expect. Importantly it also outlines the contribution that self management can make in ensuring the best outcomes for personal health and well-being and quality of life. (p) Physical and Sensory Disability Strategy 2011-2015 This strategy, which was launched in February 2012, confirms the Department s commitment to improving outcomes, services and support for people in Northern Ireland who have a physical, communication or sensory disability. It has been developed in accordance with the articles stated in the United Nation s Convention on the Rights of Persons with Disabilities and therefore 265

supports the values of dignity, respect, independence, choice, equality and anti-discrimination for disabled people. The principles of family and person-centred care and self directed support are promoted throughout the strategy and recognition is given to the need to adopt a life cycle approach to the provision of services and support. The requirement for integrated working, not just across government departments and health and social care organisations, but also in partnership with the third sector is emphasised throughout the document. (q) Developing Advocacy Services: A Policy Guide for Commissioners (May 2012). The Policy Guide includes definitions of independent advocacy in the HSC context, concentrating on the types that empower individual and groups to access services and shape them to improve their independence and quality of life. Types include peer advocacy through to professional advocacy for those who may have limited capacity to speak up on their own behalf. The Policy Guide also includes agreed standards for independent advocacy services and commissioning principles for the development of new services. HSCB has an associated action plan to implement the Policy Guide. The main features are: Mapping service availability independent advocacy services across the region in the light of the DHSSPS definitions. Improving services by implementing service standards. A code of conduct and common induction plan for advocates. Improving awareness and promoting the benefits of independent advocacy with HSC staff, service users and family carers. POLICY IN DEVELOPMENT 1. The Development of Government Policy on Safeguarding Vulnerable Adults There has been a growing recognition that a wide range of adults, including older people, for a variety of reasons are at risk of harm from abuse, exploitation or neglect. The Department, jointly with the Department of Justice and with input from other Government Departments, is taking forward the development of a Safeguarding Vulnerable Adult Policy Framework. This will stipulate a number of 266

policy objectives ranging from the prevention of adult abuse through implementation of good safeguarding arrangements to effective protective responses from lead protection agencies (principally the police and social services) when adult abuse occurs or is suspected. The aim is to begin to shift the balance of emphasis towards safeguarding (keeping adults safe and helping them to keep themselves safe) and away from protection (being reactive to abuse), without exposing any vulnerable adult to unnecessary risk. The intention is to take account of policy developments in this arena in other jurisdictions and to issue a draft policy framework for public consultation during 2013. In this context Safeguarding Vulnerable Adults - Regional Adult Protection Policy and Procedural Guidance (September 2006) and the associated Protocol for Joint Investigation of Alleged and Suspected Cases of Abuse of Vulnerable Adults (July 2009) will be reviewed and updated. The purpose of the guidance is to ensure a coordinated and standardised approach by all those who work with vulnerable adults, including older people, and to establish the principles of good practice in this important area of work.. 2. Transforming Your Care A Review of Health and Social Care in Northern Ireland This Review which published in December 2011 by the Board, seeks to provide a strategic assessment across all aspects of health and social care services, examining the present quality and accessibility of services, and the extent to which the needs of patients, clients, carers and communities are being met. The Review identified 12 major principles for change, which should underpin the shape of the future model proposed for health and social care. 3. The Reform of Adult Care and Support This is a three stage process of reform tasked with identifying the future direction and funding of adult care and support. Stage One, a six month consultation on the discussion document, Who Cares? The Future of Adult Care and Support,concluded on 15 March 2015. Analysis of consultation responses is currently underway before the project moves to stage two which will see the development of proposals for change which will then also be subject to consultation. The proposals will include potential changes to how people contribute to the cost of care and support. 267

Stage three will then identify the final, agreed policy direction together with any necessary legislative amendments. 4. Mental Health and Wellbeing Promotion Strategy This will have a discrete section on the promotion of improved mental health and wellbeing in older people. Older people have been identified as a priority group. The Strategy will recognise that people over 65 are more likely to have a range of additional risk factors for mental health problems, including living alone, having poor health and/or difficulties with everyday activities. 268

Produced by: Department of Health, Social Services and Public Safety, Castle Buildings, Belfast BT4 3SQ Telephone (028) 9052 2424 http://www.dhsspsni.gov.uk September 2013 269