Comment by the Associate Chief Nursing Officer
The care of people with dementia is a high priority for the Scottish Government and the Chief Nursing Officer Directorate. A number of very important initiatives, such as the Quality and Excellence in Specialist Dementia Care (QESDC) programme of work, are consequently being driven forward to ensure that people with dementia and their carers receive the best possible services at all stages of the condition, from diagnosis to end of life.
As part of this endeavour, we conducted this survey of NHS boards in Scotland to provide a baseline of services being delivered in specialist dementia care settings. We wanted to identify good practice that could be shared, but also areas in which improvement was needed. Commitment 11 of Scotland's National Dementia Strategy 2013-2016, which includes specialist mental health dementia care settings, provided an ideal framework from which to take the work forward.
The survey results show us that much of the practice in boards is of good quality. Boards and their staff are working hard to ensure that people with dementia and their carers receive comprehensive assessments of their needs at or close to admission and that carers are made to feel valued contributors to care-planning and delivery. They are complying with policy and legislative requirements across a range of areas, demonstrating not only awareness of their responsibilities, but also practical application of statute.
The survey suggests that the needs of people at particular stages, such as end of life, are being sensitively and appropriately addressed. Evidence emerges of ward teams seeking the expertise of specialist palliative and end-of-life services and pursuing education to help them deliver the care people need at this crucial life stage. They are also applying national guidance around DNACPR orders and end-of-life care and using validated tools to enable them to assess vital issues such as patients' pain levels.
Enthusiasm and willingness to pursue non-pharmacological models of care is clearly demonstrated. Boards provide evidence of appropriate review procedures in place to ensure people with dementia receive only those medicines they need, but just as important, staff are looking to meaningful activities to engage with people, help them realise value in their lives once again and avoid, if possible, the occurrence of stress and distress. Part of this involves the creation of a calming and therapeutic physical environment, and the survey provides examples of ward staff working with colleagues in boards to bring about changes in ward design. Many of these changes are relatively simple - posting appropriate signage, for example - but it is recognised that little things can make a big difference. It is striking too to find that a number of staff have trained in dementia design at Stirling University, are using environmental tools from the Dementia Services Development Centre and are contributing to high-level NHS board groups looking into environmental and design issues.
Safety is clearly a vital element of care for all patients and staff in NHSScotland, but the three specific areas highlighted in Commitment 11 - food, fluid and nutrition, pressure area care/continence care, and falls - have particular resonance for people living with dementia, many of whom have physical and mental conditions that make them particularly vulnerable. The survey provides examples of staff in the boards demonstrating awareness of this by taking measures to ensure appropriate risk assessments are completed for every patient and safeguards are in place in wards and units. But they are doing so with an acute consciousness that the understandable desire to protect patients from harm must be balanced by a recognition that patients have rights, that over-protection can lead to increasing dependence, and that people's dignity must be respected and maintained.
It is encouraging to see the educational opportunities available at board and national levels to help staff achieve the understanding and competence they need to care for people with dementia and their carers. The Promoting Excellence Framework is the bedrock of this educational endeavour and is providing a national structure not only for assessing staff education needs, but also for determining workforce requirements. With the KSF, personal development plans, clinical supervision, the NMWWPP tools (particularly the Mental Health Nursing Workforce Planning Tool) and other mechanisms boards have at their disposal, a powerful structure for workforce planning and development in dementia services emerges.
Strong leadership is central to the delivery of person-centred, safe and effective services, and the survey provides evidence of strategic and clinical leadership involvement in dementia services. Leaders at the very top levels of some boards are actively engaged in promoting quality in dementia care and senior charge nurses are using the tools and strategies provided by Leading Better Care to drive improvement for their patients and staff by setting standards and auditing quality.
Staff caring for people with dementia and their carers often work in difficult circumstances with patients whose complex needs require a high degree of skill, sensitivity and innovation. The survey suggests that NHS boards have in place the fundamental structures to support staff to provide the care these patients and carers require. There is undoubtedly, however, some way to go, and the need to drive ongoing improvement in services must remain a priority for all NHSScotland specialist dementia care settings.
We have therefore commissioned Healthcare Improvement Scotland to commence improvement and scrutiny work in specialist dementia care settings. While the full details are still to be finalised, this will most probably include a quality improvement programme to support boards to make changes and drive improvements in practice that will be complemented, over time, by a scrutiny programme. The initial focus, however, will be on getting the improvement programme into the wards to help staff develop the services they offer.
On behalf of the Chief Nursing Officer Directorate, I would like to thank all of the board staff who conducted the surveys on which this report is based and developed improvement plans to address the weaknesses they identified. Your determination, commitment, skill, knowledge and compassion are NHSScotland's greatest assets in improving the lives of people with dementia and their carers.
Associate Chief Nursing Officer, Chief Nursing Officer
Directorate Scottish Government
For more information, contact Vicky Thompson at: Victoria.Thompson@gov.scot
Email: Ian Roxburgh
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